Provider Demographics
NPI:1508557141
Name:MOODY, SALLY (CNA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4711
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33424-4711
Mailing Address - Country:US
Mailing Address - Phone:561-634-1206
Mailing Address - Fax:
Practice Address - Street 1:5041 MASSY DR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-7485
Practice Address - Country:US
Practice Address - Phone:561-634-1206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health