Provider Demographics
NPI:1831832195
Name:MOORE, SHIRLEY ANN
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:ANN
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 1:1360 S 5TH ST STE 356C
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2449
Mailing Address - Country:US
Mailing Address - Phone:844-273-2700
Mailing Address - Fax:
Practice Address - Street 1:1360 S 5TH ST STE 356C
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2449
Practice Address - Country:US
Practice Address - Phone:844-273-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 253Z00000X, 343900000X, 347E00000X
MO26D2254172291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347E00000XTransportation ServicesTransportation Broker