Provider Demographics
NPI:1629678271
Name:MOORE, JENNETTA SHIMELL (LPN)
Entity Type:Individual
Prefix:
First Name:JENNETTA
Middle Name:SHIMELL
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 1:3215 OLD VINEYARD RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1411
Mailing Address - Country:US
Mailing Address - Phone:336-354-9047
Mailing Address - Fax:
Practice Address - Street 1:3215 OLD VINEYARD RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1411
Practice Address - Country:US
Practice Address - Phone:336-354-9047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC90648164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse