Healthcare Provider Details

I. General information

NPI: 1275824120
Provider Name (Legal Business Name): BRENDA KAY MOORE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

825 OUTLAW RD UNIT 73
CHURCH ROCK NM
87311-0014
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1253
  • Fax:
Mailing address:
  • Phone: 832-686-1965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number009519
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: