Provider Demographics
NPI:1225808512
Name:FOXMOOR, SHANNETTA
Entity Type:Individual
Prefix:MRS
First Name:SHANNETTA
Middle Name:
Last Name:FOXMOOR
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 1:406 WILMORE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-8384
Mailing Address - Country:US
Mailing Address - Phone:302-230-1185
Mailing Address - Fax:
Practice Address - Street 1:406 WILMORE DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-8384
Practice Address - Country:US
Practice Address - Phone:302-230-1185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA335E00000X
NJ335E00000X
DE335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier