Provider Demographics
NPI:1689283590
Name:MOORE, SHANQUITA
Entity Type:Individual
Prefix:
First Name:SHANQUITA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9602 SEAVIEW DR APT 101
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34788-7699
Mailing Address - Country:US
Mailing Address - Phone:850-960-3277
Mailing Address - Fax:
Practice Address - Street 1:9602 SEAVIEW DR APT 101
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-7699
Practice Address - Country:US
Practice Address - Phone:850-960-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000000000Medicaid