Provider Demographics
NPI:1497214811
Name:MOORE, SHAUNINA MARIE
Entity Type:Individual
Prefix:
First Name:SHAUNINA
Middle Name:MARIE
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 1:3924 SW 52ND AVE UNIT C5
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33023-7903
Mailing Address - Country:US
Mailing Address - Phone:786-985-7911
Mailing Address - Fax:
Practice Address - Street 1:3600 S STATE ROAD 7 STE 241
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023-5289
Practice Address - Country:US
Practice Address - Phone:954-983-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2019-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL374U00000X, 385H00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Single Specialty