Provider Demographics
NPI:1326488875
Name:MOODY, JOHNNY BURTON JR (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:BURTON
Last Name:MOODY
Suffix:JR
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6903 PARK SHARON CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-4612
Mailing Address - Country:US
Mailing Address - Phone:828-279-5381
Mailing Address - Fax:
Practice Address - Street 1:3680 ROBINWOOD RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1676
Practice Address - Country:US
Practice Address - Phone:704-869-9701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006262363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily