Provider Demographics
NPI:1386166858
Name:MOELLER, SHONTE
Entity type:Individual
Prefix:
First Name:SHONTE
Middle Name:
Last Name:MOELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHONTE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA CERTIFIED
Mailing Address - Street 1:514 N FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1936
Mailing Address - Country:US
Mailing Address - Phone:217-220-9627
Mailing Address - Fax:
Practice Address - Street 1:815 W COLLEGE AVE APT 4
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3800
Practice Address - Country:US
Practice Address - Phone:217-220-8136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide