Provider Demographics
NPI:1093316663
Name:MOODY, SAMANTHA JO (FNP-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:MOODY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-1035
Mailing Address - Country:US
Mailing Address - Phone:269-625-0177
Mailing Address - Fax:
Practice Address - Street 1:658 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032-9627
Practice Address - Country:US
Practice Address - Phone:269-467-3228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704314094363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily