Provider Demographics
NPI:1639414345
Name:MOORE, SHANNON L (LPN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
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 1:1235 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:SEDRO-WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284
Mailing Address - Country:US
Mailing Address - Phone:360-855-3510
Mailing Address - Fax:
Practice Address - Street 1:1235 3RD STREET
Practice Address - Street 2:
Practice Address - City:SEDRO-WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284
Practice Address - Country:US
Practice Address - Phone:360-855-3510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00054619164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse