Healthcare Provider Details

I. General information

NPI: 1548124894
Provider Name (Legal Business Name): MS. SHAMAINE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 W FAIRMOUNT AVE
MILWAUKEE WI
53209-5523
US

IV. Provider business mailing address

4971 N 27TH ST
MILWAUKEE WI
53209-5512
US

V. Phone/Fax

Practice location:
  • Phone: 414-426-4535
  • Fax:
Mailing address:
  • Phone: 414-204-5755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number0020756
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: