Provider Demographics
NPI:1265755649
Name:MOSHURE, SHANNA LEA (AUD)
Entity type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:LEA
Last Name:MOSHURE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S SHIELDS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1827
Mailing Address - Country:US
Mailing Address - Phone:970-493-5334
Mailing Address - Fax:
Practice Address - Street 1:2001 S SHIELDS ST STE 101
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1827
Practice Address - Country:US
Practice Address - Phone:970-493-5334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAUD.0000844231H00000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO330080487Medicaid