Provider Demographics
NPI:1215436423
Name:MOORE, JENITRE SHAVONNE (CRNA)
Entity type:Individual
Prefix:
First Name:JENITRE
Middle Name:SHAVONNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5885 EDENFIELD RD APT L32
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-1203
Mailing Address - Country:US
Mailing Address - Phone:912-980-7461
Mailing Address - Fax:
Practice Address - Street 1:5885 EDENFIELD RD APT L32
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-1203
Practice Address - Country:US
Practice Address - Phone:912-980-7461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-03
Last Update Date:2018-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9316340367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered