Provider Demographics
NPI:1215545363
Name:MOORE, SHENELL (RMA)
Entity Type:Individual
Prefix:
First Name:SHENELL
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 GOSTLIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46327-1302
Mailing Address - Country:US
Mailing Address - Phone:708-953-2575
Mailing Address - Fax:219-289-9108
Practice Address - Street 1:225 GOSTLIN ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46327-1302
Practice Address - Country:US
Practice Address - Phone:708-953-2575
Practice Address - Fax:219-289-9108
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2811784246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN202006291401707OtherHOME HEALTH