Basic Information
| Provider Information | |||||||||
| NPI: | 1902343569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILGORE | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | MAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1989 | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825010240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078579490 | ||||||||
| FaxNumber: | 3073330450 | ||||||||
| Practice Location | |||||||||
| Address1: | 10269 HIGHWAY 789 | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825018829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078579490 | ||||||||
| FaxNumber: | 3073330450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2017 | ||||||||
| LastUpdateDate: | 08/24/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.