Provider Demographics
NPI:1194557306
Name:GILMORE, MONIQUE CRYSTAL
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:CRYSTAL
Last Name:GILMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1172 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-2556
Mailing Address - Country:US
Mailing Address - Phone:805-801-2231
Mailing Address - Fax:
Practice Address - Street 1:227 S HALCYON RD STE 101
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3174
Practice Address - Country:US
Practice Address - Phone:805-801-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-16
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program