Basic Information
| Provider Information | |||||||||
| NPI: | 1871231324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOIT | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | LEEANN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STULL | ||||||||
| OtherFirstName: | SHELBY | ||||||||
| OtherMiddleName: | LEEANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RBT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 INTERNATIONAL PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327465028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666100580 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3817 CONSTITUTION DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799221367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152260367 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2022 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | 222223146 | TX | Y |
No ID Information.