Provider Demographics
NPI:1396353397
Name:GILMORE, JOHN (FNP-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GILMORE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2395 LAKE SHORE DR S
Mailing Address - Street 2:
Mailing Address - City:GOREVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62939-3167
Mailing Address - Country:US
Mailing Address - Phone:224-316-0402
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:618-997-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021629363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily