MEDICARE: SHALISHA HANNAH MOORE LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	328735	NY

General Provider Information

NPI Number	:	1487175873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHALISHA HANNAH MOORE LPN

Provider Business Mailing Address
First Line	:	25 GARDEN VILLAGE DR APT 1
Second Line	:
City	:	CHEEKTOWAGA
State	:	NY
Zip	:	14227-3376
Country	:	US
Telephone Number	:	716-880-9936
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 GARDEN VILLAGE DR APT 1
Second Line	:
City	:	CHEEKTOWAGA
State	:	NY
Zip	:	14227-3376
Country	:	US
Telephone Number	:	716-880-9936
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2017
Last Update Date	:	07/21/2022

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