Provider Demographics
NPI:1902341217
Name:MOODIE, SHAQCORE
Entity Type:Individual
Prefix:
First Name:SHAQCORE
Middle Name:
Last Name:MOODIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 E 45TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1812
Mailing Address - Country:US
Mailing Address - Phone:347-319-6727
Mailing Address - Fax:
Practice Address - Street 1:127 E 45TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1812
Practice Address - Country:US
Practice Address - Phone:347-319-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY327350-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse