Healthcare Provider Details

I. General information

NPI: 1073235859
Provider Name (Legal Business Name): GLORIA L MOORE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 PINE GROVE AVE STE 1
PORT HURON MI
48060-3370
US

IV. Provider business mailing address

5316 LAKESHORE RD
FORT GRATIOT MI
48059-3118
US

V. Phone/Fax

Practice location:
  • Phone: 810-357-8769
  • Fax:
Mailing address:
  • Phone: 810-357-8792
  • Fax: 810-512-7725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WX1500X
TaxonomyOstomy Care Registered Nurse
License Number4704263386
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number4704263386
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704263386
License Number StateMI
# 8
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704301246NSA220SA
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: