Basic Information
| Provider Information | |||||||||
| NPI: | 1114267572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | CALLA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 EAST AVE STE 3G | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068515727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038384034 | ||||||||
| FaxNumber: | 2038536351 | ||||||||
| Practice Location | |||||||||
| Address1: | 148 EAST AVE STE 3G | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068515727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038384034 | ||||||||
| FaxNumber: | 2038536361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2013 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 382340 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363L00000X | 18499739 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.