Healthcare Provider Details

I. General information

NPI: 1669933438
Provider Name (Legal Business Name): SHONDA LASHAY MOORE-STEVENS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 PRESTWOOD RD
ALBERTA VA
23821
US

IV. Provider business mailing address

775 PRESTWOOD RD
ALBERTA VA
23821
US

V. Phone/Fax

Practice location:
  • Phone: 804-677-0732
  • Fax: 434-532-4294
Mailing address:
  • Phone: 804-677-0732
  • Fax: 434-532-4294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberT64272744
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: