Provider Demographics
NPI:1144363037
Name:MOORE, GWENDOLYN (MPH, RD)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MPH, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 WHITE CAP LN
Mailing Address - Street 2:
Mailing Address - City:NEWPORT COAST
Mailing Address - State:CA
Mailing Address - Zip Code:92657-1096
Mailing Address - Country:US
Mailing Address - Phone:714-552-3802
Mailing Address - Fax:866-704-4779
Practice Address - Street 1:7777 MILLIKEN AVE STE 360
Practice Address - Street 2:#2
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6782
Practice Address - Country:US
Practice Address - Phone:714-552-3802
Practice Address - Fax:866-704-4779
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA976489133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered