MEDICARE: GLORIA L MOORE FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor
3	163WX1500X	Ostomy Care Registered Nurse	4704263386	MI
4	225200000X	Physical Therapy Assistant
5	1041C0700X	Clinical Social Worker
6	163WW0000X	Wound Care Registered Nurse	4704263386	MI
7	363LP2300X	Primary Care Nurse Practitioner	4704263386	MI
8	101YA0400X	Addiction (Substance Use Disorder) Counselor
9	363LF0000X	Family Nurse Practitioner	4704301246NSA220SA	MI

General Provider Information

NPI Number	:	1073235859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORIA L MOORE FNP

Provider Business Mailing Address
First Line	:	5316 LAKESHORE RD
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3118
Country	:	US
Telephone Number	:	810-357-8792
Fax Number	:	810-512-7725

Provider Business Practice Location Address
First Line	:	1530 PINE GROVE AVE STE 1
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-3370
Country	:	US
Telephone Number	:	810-357-8769
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2022
Last Update Date	:	11/06/2024

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