Provider Demographics
NPI:1750419909
Name:MOORE, SHANNON MARIE (MPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 OAKEN PL
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27539-7773
Mailing Address - Country:US
Mailing Address - Phone:813-486-7903
Mailing Address - Fax:
Practice Address - Street 1:1000 TANDAL PL
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-8842
Practice Address - Country:US
Practice Address - Phone:804-269-0350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist