MEDICARE: MS. GLENDA IRENE 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	363LP2300X	Primary Care Nurse Practitioner	514085	CA

General Provider Information

NPI Number	:	1083698393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GLENDA IRENE MOORE FNP

Provider Business Mailing Address
First Line	:	306 MERCURY WAY
Second Line	:
City	:	PLEASANT HILL
State	:	CA
Zip	:	94523-2185
Country	:	US
Telephone Number	:	925-676-0743
Fax Number	:

Provider Business Practice Location Address
First Line	:	2505 W 14TH ST
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94607-5031
Country	:	US
Telephone Number	:	510-587-3400
Fax Number	:

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

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	10/14/2015

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