Provider Demographics
NPI:1386530889
Name:GILMORE, KARISSA CARRIE
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:CARRIE
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 1:2407 SE MARIUS ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7276
Mailing Address - Country:US
Mailing Address - Phone:772-812-6056
Mailing Address - Fax:
Practice Address - Street 1:518 SW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8734
Practice Address - Country:US
Practice Address - Phone:772-873-8811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLG240-129-67-600-0171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator