Healthcare Provider Details

I. General information

NPI: 1487657037
Provider Name (Legal Business Name): SHELLY L. MOORE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1263 ELK ST
FRANKLIN PA
16323-1312
US

IV. Provider business mailing address

1263 ELK ST
FRANKLIN PA
16323-1312
US

V. Phone/Fax

Practice location:
  • Phone: 814-437-3674
  • Fax: 814-437-3677
Mailing address:
  • Phone: 814-437-3674
  • Fax: 814-437-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberTP006751B
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: