Provider Demographics
NPI:1669031498
Name:MOORE, SHANA LOLETA (MA)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:LOLETA
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:LOLETA
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 HOLLY SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-6204
Mailing Address - Country:US
Mailing Address - Phone:984-225-2558
Mailing Address - Fax:
Practice Address - Street 1:500 HOLLY SPRINGS RD
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-6204
Practice Address - Country:US
Practice Address - Phone:984-225-2558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13297231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty