Provider Demographics
NPI:1073235859
Name:MOORE, GLORIA L (FNP)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5316 LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3118
Mailing Address - Country:US
Mailing Address - Phone:810-357-8792
Mailing Address - Fax:810-512-7725
Practice Address - Street 1:2601 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6587
Practice Address - Country:US
Practice Address - Phone:810-216-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704301246207RS0012X
MI4704263386163WW0000X, 163WX1500X, 363LP2300X
225200000X
MI4704301246NSA220SA363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163WX1500XNursing Service ProvidersRegistered NurseOstomy Care
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care