Provider Demographics
NPI:1013363449
Name:MOORE, GWENDOLYN LAYETTE (RN)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:LAYETTE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 OLD COLONY RD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-3200
Mailing Address - Country:US
Mailing Address - Phone:269-312-8858
Mailing Address - Fax:269-312-8789
Practice Address - Street 1:4441 OLD COLONY ROAD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008
Practice Address - Country:US
Practice Address - Phone:269-312-8858
Practice Address - Fax:269-312-8789
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI81-068-4911374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide