Provider Demographics
NPI:1891567491
Name:WILLIAMS MOORE, QUANTANIQUE SHANTE (LMT, CHD)
Entity Type:Individual
Prefix:
First Name:QUANTANIQUE
Middle Name:SHANTE
Last Name:WILLIAMS MOORE
Suffix:
Gender:F
Credentials:LMT, CHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 KACHINA DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-3025
Mailing Address - Country:US
Mailing Address - Phone:562-810-9195
Mailing Address - Fax:
Practice Address - Street 1:1155 KACHINA DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-3025
Practice Address - Country:US
Practice Address - Phone:562-810-9195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
COMT.0024894225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty