Provider Demographics
NPI:1083698393
Name:MOORE, GLENDA IRENE (FNP)
Entity Type:Individual
Prefix:MS
First Name:GLENDA
Middle Name:IRENE
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 1:306 MERCURY WAY
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-2185
Mailing Address - Country:US
Mailing Address - Phone:925-676-0743
Mailing Address - Fax:
Practice Address - Street 1:2505 W 14TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-5031
Practice Address - Country:US
Practice Address - Phone:510-587-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA514085363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care