Healthcare Provider Details

I. General information

NPI: 1679824098
Provider Name (Legal Business Name): SHAREA N MOORE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHAREA N MOORE NP

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 MCDONOUGH BLVD SE
ATLANTA GA
30315-4400
US

IV. Provider business mailing address

PO BOX 870347
STONE MOUNTAIN GA
30087-0009
US

V. Phone/Fax

Practice location:
  • Phone: 404-635-5467
  • Fax:
Mailing address:
  • Phone: 770-910-3744
  • Fax: 404-601-6760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF0912305
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN207060
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0912305
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN207060
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: