Provider Demographics
NPI:1417142753
Name:MOODY, DORI ANN
Entity Type:Individual
Prefix:
First Name:DORI
Middle Name:ANN
Last Name:MOODY
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 1:2705B EDGEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-1584
Mailing Address - Country:US
Mailing Address - Phone:254-813-1578
Mailing Address - Fax:
Practice Address - Street 1:2705B EDGEFIELD ST
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-1584
Practice Address - Country:US
Practice Address - Phone:254-813-1578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX90897164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse