Healthcare Provider Details

I. General information

NPI: 1962582585
Provider Name (Legal Business Name): GALE MOORE C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 OAK ST
GRENADA MS
38901-4633
US

IV. Provider business mailing address

1401 OAK ST
GRENADA MS
38901-4633
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-4010
  • Fax: 662-226-4495
Mailing address:
  • Phone: 662-226-4010
  • Fax: 662-226-4495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberR525294
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberR525294
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: