Provider Demographics
NPI:1144892381
Name:MOORE, SHEFANIE RAYCHEL
Entity type:Individual
Prefix:MRS
First Name:SHEFANIE
Middle Name:RAYCHEL
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 1:2300 GREENWOOD RD
Mailing Address - Street 2:ATTN: RECOVERY AUDIT
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103
Mailing Address - Country:US
Mailing Address - Phone:318-212-2695
Mailing Address - Fax:318-212-2689
Practice Address - Street 1:2300 GREENWOOD RD
Practice Address - Street 2:ATTN: RECOVERY AUDIT
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103
Practice Address - Country:US
Practice Address - Phone:318-212-2695
Practice Address - Fax:318-212-2689
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization