Provider Demographics
NPI:1902343569
Name:KILGORE, NICHOLE MAE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MAE
Last Name:KILGORE
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:PO BOX 1989
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-0240
Mailing Address - Country:US
Mailing Address - Phone:307-857-9490
Mailing Address - Fax:307-333-0450
Practice Address - Street 1:10269 HIGHWAY 789
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-8829
Practice Address - Country:US
Practice Address - Phone:307-857-9490
Practice Address - Fax:307-333-0450
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker