Healthcare Provider Details

I. General information

NPI: 1730012303
Provider Name (Legal Business Name): SHANNON MORIARTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 DELAWARE AVE
MALABAR FL
32950-3807
US

IV. Provider business mailing address

1505 DELAWARE AVE
MALABAR FL
32950-3807
US

V. Phone/Fax

Practice location:
  • Phone: 321-243-5951
  • Fax:
Mailing address:
  • Phone: 321-243-5951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN11042356
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: