Provider Demographics
NPI:1225742422
Name:MOSS, SHENEAK SHONTEL
Entity Type:Individual
Prefix:
First Name:SHENEAK
Middle Name:SHONTEL
Last Name:MOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 W DOLING LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-2176
Mailing Address - Country:US
Mailing Address - Phone:417-258-5824
Mailing Address - Fax:
Practice Address - Street 1:1419 W DOLING LN
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-2176
Practice Address - Country:US
Practice Address - Phone:417-258-5824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOBUS2021-01538342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company