Provider Demographics
NPI:1114267572
Name:MOORE, GWENDOLYN CALLA (CPNP)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:CALLA
Last Name:MOORE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 EAST AVE STE 3G
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5727
Mailing Address - Country:US
Mailing Address - Phone:203-838-4034
Mailing Address - Fax:203-853-6351
Practice Address - Street 1:148 EAST AVE STE 3G
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-5727
Practice Address - Country:US
Practice Address - Phone:203-838-4034
Practice Address - Fax:203-853-6361
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382340363LP0200X
CT18499739363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics