Provider Demographics
NPI:1770742470
Name:MOORE, LASHAWNE RENEE (LPN)
Entity type:Individual
Prefix:MS
First Name:LASHAWNE
Middle Name:RENEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W HOSPITAL RD RM 11C17
Mailing Address - Street 2:ATTN: OFFICE OF GRADUATE MEDICAL EDUCATION
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:706-787-1745
Mailing Address - Fax:
Practice Address - Street 1:300 W HOSPITAL RD RM 11C17
Practice Address - Street 2:ATTN: OFFICE OF GRADUATE MEDICAL EDUCATION
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:706-787-1745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN055869164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVAD 000Medicare UPIN