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 1:1530 PINE GROVE AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3370
Practice Address - Country:US
Practice Address - Phone:810-357-8769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X, 225200000X, 1041C0700X, 101YA0400X
MI4704263386163WX1500X, 163WW0000X, 363LP2300X
MI4704301246NSA220SA363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163WX1500XNursing Service ProvidersRegistered NurseOstomy Care
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily