Provider Demographics
NPI:1740331214
Name:GILMORE, KELLY A (LPN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:GILMORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:348 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2129
Mailing Address - Country:US
Mailing Address - Phone:315-363-7025
Mailing Address - Fax:
Practice Address - Street 1:506 NEW BOSTON ST
Practice Address - Street 2:
Practice Address - City:CANASTOTA
Practice Address - State:NY
Practice Address - Zip Code:13032-4386
Practice Address - Country:US
Practice Address - Phone:315-697-5460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246802164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02121117Medicaid