Basic Information
| Provider Information | |||||||||
| NPI: | 1609529866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 395 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707220395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256835292 | ||||||||
| FaxNumber: | 2256833411 | ||||||||
| Practice Location | |||||||||
| Address1: | 28315 S FROST RD | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707542612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252831356 | ||||||||
| FaxNumber: | 2256862962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2022 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 224079 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 224079 | 01 | LA | FNP LICENSE | OTHER |