Provider Demographics
NPI:1477547511
Name:MOODY, CHRISTOPHER WARD (CPNP)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:WARD
Last Name:MOODY
Suffix:
Gender:M
Credentials:CPNP
Other - Prefix:MR
Other - First Name:CHRISTOPHER
Other - Middle Name:WARD
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPNP
Mailing Address - Street 1:380 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2260
Mailing Address - Country:US
Mailing Address - Phone:860-274-8891
Mailing Address - Fax:860-274-8895
Practice Address - Street 1:380 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2260
Practice Address - Country:US
Practice Address - Phone:860-274-8891
Practice Address - Fax:860-274-8895
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001457363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics