Healthcare Provider Details

I. General information

NPI: 1225960750
Provider Name (Legal Business Name): SHAUN TERELLE MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6010 WENNINGHOFF RD
OMAHA NE
68134-1903
US

IV. Provider business mailing address

3123 S 69TH AVE APT 2
OMAHA NE
68106-3554
US

V. Phone/Fax

Practice location:
  • Phone: 402-618-4535
  • Fax:
Mailing address:
  • Phone: 402-618-4535
  • Fax: 531-344-6454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: