Provider Demographics
NPI:1508212796
Name:MORENO, JODY LEE
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LEE
Last Name:MORENO
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 1:3991 BRUTON RD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33565-7023
Mailing Address - Country:US
Mailing Address - Phone:813-716-9698
Mailing Address - Fax:
Practice Address - Street 1:3440 HOLLYWOOD BLVD STE 460
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6933
Practice Address - Country:US
Practice Address - Phone:954-923-7440
Practice Address - Fax:866-968-6339
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9329228363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily