Provider Demographics
NPI:1679824098
Name:MOORE, SHAREA N (NP)
Entity Type:Individual
Prefix:MRS
First Name:SHAREA
Middle Name:N
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHAREA
Other - Middle Name:N
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 870347
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-0009
Mailing Address - Country:US
Mailing Address - Phone:770-910-3744
Mailing Address - Fax:404-601-6760
Practice Address - Street 1:601 MCDONOUGH BLVD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-4400
Practice Address - Country:US
Practice Address - Phone:404-635-5467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN207060163W00000X, 363LF0000X
GAF0912305363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner