Provider Demographics
NPI:1992284772
Name:GILMORE, SHELLY
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
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 1:208 CARSWELL ST
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-1569
Mailing Address - Country:US
Mailing Address - Phone:254-548-4538
Mailing Address - Fax:
Practice Address - Street 1:1424 MARTIN LUTHER KING JR LN
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-5941
Practice Address - Country:US
Practice Address - Phone:254-791-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-12
Last Update Date:2018-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant