Provider Demographics
NPI:1609529866
Name:MOORE, SHELBY B (FNP)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:B
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-0395
Mailing Address - Country:US
Mailing Address - Phone:225-683-5292
Mailing Address - Fax:225-683-3411
Practice Address - Street 1:28315 S FROST RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:LA
Practice Address - Zip Code:70754-2612
Practice Address - Country:US
Practice Address - Phone:225-283-1356
Practice Address - Fax:225-686-2962
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA224079363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA224079OtherFNP LICENSE