Provider Demographics
NPI:1326388893
Name:MOORE, SHANNON MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MICHELLE
Last Name:MOORE
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 1:340 RALLEY RD
Mailing Address - Street 2:
Mailing Address - City:KEAVY
Mailing Address - State:KY
Mailing Address - Zip Code:40737-2729
Mailing Address - Country:US
Mailing Address - Phone:606-682-7333
Mailing Address - Fax:606-864-3897
Practice Address - Street 1:340 RALLEY RD
Practice Address - Street 2:
Practice Address - City:KEAVY
Practice Address - State:KY
Practice Address - Zip Code:40737-2729
Practice Address - Country:US
Practice Address - Phone:606-682-7333
Practice Address - Fax:606-864-3897
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201093768222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist