Provider Demographics
NPI:1194358317
Name:MOODY, KELLEY MARIE (NP-C)
Entity Type:Individual
Prefix:MISS
First Name:KELLEY
Middle Name:MARIE
Last Name:MOODY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 W CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-4412
Mailing Address - Country:US
Mailing Address - Phone:843-995-9990
Mailing Address - Fax:843-951-9989
Practice Address - Street 1:750 W CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4412
Practice Address - Country:US
Practice Address - Phone:843-951-9990
Practice Address - Fax:843-951-9989
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23682207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine