Provider Demographics
NPI:1245251826
Name:BRASWELL-MOORE, GLENDA MARIE (CRNAP)
Entity type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:MARIE
Last Name:BRASWELL-MOORE
Suffix:
Gender:F
Credentials:CRNAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 MAIDEN LN
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23325-4606
Mailing Address - Country:US
Mailing Address - Phone:757-424-5495
Mailing Address - Fax:
Practice Address - Street 1:736 BATTLEFIELD BLVD N
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4941
Practice Address - Country:US
Practice Address - Phone:757-312-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024057189367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAS71776Medicare UPIN