Healthcare Provider Details

I. General information

NPI: 1497285696
Provider Name (Legal Business Name): SHALANE BETH MOORE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHALANE BETH WALLACE

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 N 4TH ST
WILMINGTON NC
28401-3450
US

IV. Provider business mailing address

1932 MONROE ST
WILMINGTON NC
28401-6728
US

V. Phone/Fax

Practice location:
  • Phone: 910-202-8656
  • Fax: 910-202-8680
Mailing address:
  • Phone: 910-599-2391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number245667
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number245667
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number245667
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number245667
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: