Provider Demographics
NPI:1497326763
Name:MOORE, SHELLY SUE
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:SUE
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 1:410 FAIR LN
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-2518
Mailing Address - Country:US
Mailing Address - Phone:419-443-0059
Mailing Address - Fax:
Practice Address - Street 1:410 FAIR LN
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-2518
Practice Address - Country:US
Practice Address - Phone:419-443-0059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH406719163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse