Healthcare Provider Details

I. General information

NPI: 1083092977
Provider Name (Legal Business Name): SHANNEN MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 WATERMAN RD
BOSTON MA
02131-2218
US

IV. Provider business mailing address

10 MONROE BLVD APT 6F
LONG BEACH NY
11561-4355
US

V. Phone/Fax

Practice location:
  • Phone: 857-345-0003
  • Fax:
Mailing address:
  • Phone: 857-345-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number701502
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number383018
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: