Healthcare Provider Details

I. General information

NPI: 1144162124
Provider Name (Legal Business Name): GABRIELLE JUDITH MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S 6TH ST
HIAWATHA KS
66434-2306
US

IV. Provider business mailing address

5225 NW 46TH ST
TOPEKA KS
66618-4402
US

V. Phone/Fax

Practice location:
  • Phone: 785-742-3631
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2279
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: