Provider Demographics
NPI:1508389990
Name:HEALTHY BODY LLC
Entity Type:Organization
Organization Name:HEALTHY BODY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOLLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDANIEL MOWERY
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:925-518-6122
Mailing Address - Street 1:7619 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4133
Mailing Address - Country:US
Mailing Address - Phone:260-407-8006
Mailing Address - Fax:260-407-8006
Practice Address - Street 1:2515 LADUE LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2796
Practice Address - Country:US
Practice Address - Phone:925-518-6122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006194A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty