Provider Demographics
NPI:1730374349
Name:MOORE, SHAWNA D (APRN)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:518 PINE ST
Practice Address - Street 2:
Practice Address - City:STEELVILLE
Practice Address - State:MO
Practice Address - Zip Code:65565-6041
Practice Address - Country:US
Practice Address - Phone:573-775-5838
Practice Address - Fax:573-729-4035
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2002005693363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1730374349Medicaid
MO431560263OtherTRICARE
MO1730374349Medicaid