Healthcare Provider Details

I. General information

NPI: 1023327038
Provider Name (Legal Business Name): GEMMA B. MOORE RN, MHA, RAT-CT,LNHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2010
Last Update Date: 09/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 OSBORN ST
BROOKLYN NY
11212-5746
US

IV. Provider business mailing address

628 OSBORN ST
BROOKLYN NY
11212-5746
US

V. Phone/Fax

Practice location:
  • Phone: 646-924-7554
  • Fax:
Mailing address:
  • Phone: 646-924-7554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number436043
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: