Provider Demographics
NPI:1659713071
Name:MOORE, SHANNON LORI (MS, RD LD/N)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LORI
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, RD LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 THOMASVILLE RD STE G
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-6273
Mailing Address - Country:US
Mailing Address - Phone:850-694-3322
Mailing Address - Fax:850-298-1131
Practice Address - Street 1:1114 THOMASVILLE RD STE G
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-6273
Practice Address - Country:US
Practice Address - Phone:850-694-3322
Practice Address - Fax:850-298-1131
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4473133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered