Healthcare Provider Details

I. General information

NPI: 1689630246
Provider Name (Legal Business Name): SHANNON JESSICA MOORE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 WATERLOO RD
WARRENTON VA
20186-3011
US

IV. Provider business mailing address

528 WATERLOO RD
WARRENTON VA
20186-3011
US

V. Phone/Fax

Practice location:
  • Phone: 540-347-0555
  • Fax: 540-347-9198
Mailing address:
  • Phone: 571-276-0237
  • Fax: 540-347-9198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001510
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: