Provider Demographics
NPI:1477954642
Name:MOODY, LISA (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6788 138TH AVE NE APT 628
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-9562
Mailing Address - Country:US
Mailing Address - Phone:425-883-9116
Mailing Address - Fax:
Practice Address - Street 1:1035 244TH AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98074-3486
Practice Address - Country:US
Practice Address - Phone:425-466-9931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60107790163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool