Healthcare Provider Details

I. General information

NPI: 1710720628
Provider Name (Legal Business Name): GWENDOLYN MOORE MPH, RN, CHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2881 SQUIRE LN
MOBILE AL
36695-4219
US

IV. Provider business mailing address

312 SCHILLINGER RD S STE T
MOBILE AL
36608-5032
US

V. Phone/Fax

Practice location:
  • Phone: 916-769-9368
  • Fax:
Mailing address:
  • Phone: 251-377-9760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-160774
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: