Healthcare Provider Details

I. General information

NPI: 1407761075
Provider Name (Legal Business Name): DEBRA SHELIA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BROADMOOR ST
MONROE LA
71203-4132
US

IV. Provider business mailing address

500 BROADMOOR ST
MONROE LA
71203-4132
US

V. Phone/Fax

Practice location:
  • Phone: 318-331-0280
  • Fax:
Mailing address:
  • Phone: 318-331-0280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number011158127
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: