MEDICARE: GENA M GORE FNP-BC, DCNP

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	363LF0000X	Family Nurse Practitioner	71005439A	IN

General Provider Information

NPI Number	:	1376959692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENA M GORE FNP-BC, DCNP

Provider Business Mailing Address
First Line	:	801 YORK ST
Second Line	:
City	:	MANITOWOC
State	:	WI
Zip	:	54220-4630
Country	:	US
Telephone Number	:	920-663-9008
Fax Number	:	920-684-1439

Provider Business Practice Location Address
First Line	:	6320 N COLLEGE AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-1706
Country	:	US
Telephone Number	:	317-348-3160
Fax Number	:	317-497-3739

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

Provider Enumeration Date	:	07/08/2014
Last Update Date	:	01/20/2026

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