Provider Demographics
NPI:1962582585
Name:MOORE, GALE (CNM)
Entity type:Individual
Prefix:
First Name:GALE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 OAK ST
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4633
Mailing Address - Country:US
Mailing Address - Phone:662-226-4010
Mailing Address - Fax:662-226-4495
Practice Address - Street 1:1401 OAK ST
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4633
Practice Address - Country:US
Practice Address - Phone:662-226-4010
Practice Address - Fax:662-226-4495
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR525294363LX0001X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00111153Medicaid
MS00111153Medicaid