Provider Demographics
NPI:1518575570
Name:MOODY, AUTUMN N (LVN)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:N
Last Name:MOODY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 RICHVALE LN
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-2552
Mailing Address - Country:US
Mailing Address - Phone:607-767-1174
Mailing Address - Fax:
Practice Address - Street 1:319 RICHVALE LN
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-2552
Practice Address - Country:US
Practice Address - Phone:607-767-1174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1001599164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse