Provider Demographics
NPI:1295221802
Name:MOODIE, ANGELA MARIE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:MOODIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 REDWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-4571
Mailing Address - Country:US
Mailing Address - Phone:386-882-0063
Mailing Address - Fax:
Practice Address - Street 1:1700 RIDGEWOOD AVE
Practice Address - Street 2:STE H
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-1782
Practice Address - Country:US
Practice Address - Phone:386-882-0063
Practice Address - Fax:386-281-3370
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9185253363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner