Provider Demographics
NPI:1710720628
Name:MOORE, GWENDOLYN (MPH, RN, CHC)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MPH, RN, CHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 SCHILLINGER RD S STE T
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-5032
Mailing Address - Country:US
Mailing Address - Phone:251-377-9760
Mailing Address - Fax:
Practice Address - Street 1:2881 SQUIRE LN
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-4219
Practice Address - Country:US
Practice Address - Phone:916-769-9368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X
AL1-160774163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No171400000XOther Service ProvidersHealth & Wellness Coach