Healthcare Provider Details

I. General information

NPI: 1730374349
Provider Name (Legal Business Name): SHAWNA D MOORE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 PINE ST
STEELVILLE MO
65565-6041
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 573-775-5838
  • Fax: 573-729-4035
Mailing address:
  • Phone: 417-829-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2002005693
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: