Healthcare Provider Details

I. General information

NPI: 1891567491
Provider Name (Legal Business Name): QUANTANIQUE SHANTE WILLIAMS MOORE LMT, CHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 KACHINA DR
COLORADO SPRINGS CO
80915-3025
US

IV. Provider business mailing address

1155 KACHINA DR
COLORADO SPRINGS CO
80915-3025
US

V. Phone/Fax

Practice location:
  • Phone: 562-810-9195
  • Fax:
Mailing address:
  • Phone: 562-810-9195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT.0024894
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: