Provider Demographics
NPI:1629388509
Name:MOORE, SHARONDA MONIQUE (LPN)
Entity Type:Individual
Prefix:
First Name:SHARONDA
Middle Name:MONIQUE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 KENILWORTH AVE NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-5412
Mailing Address - Country:US
Mailing Address - Phone:330-883-6499
Mailing Address - Fax:
Practice Address - Street 1:311 KENILWORTH AVE NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-5412
Practice Address - Country:US
Practice Address - Phone:330-883-6499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH127818164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse