Provider Demographics
NPI:1487657037
Name:MOORE, SHELLY L (CRNP)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1263 ELK ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:PA
Mailing Address - Zip Code:16323-1312
Mailing Address - Country:US
Mailing Address - Phone:814-437-3674
Mailing Address - Fax:814-437-3677
Practice Address - Street 1:1263 ELK ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:PA
Practice Address - Zip Code:16323-1312
Practice Address - Country:US
Practice Address - Phone:814-437-3674
Practice Address - Fax:814-437-3677
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP006751B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P21571Medicare UPIN