Provider Demographics
NPI:1598239907
Name:MOODIE, MARCIA MARIE
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:MARIE
Last Name:MOODIE
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 1:6107 NW 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-5663
Mailing Address - Country:US
Mailing Address - Phone:305-308-9771
Mailing Address - Fax:
Practice Address - Street 1:6107 NW 69TH AVE
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-5663
Practice Address - Country:US
Practice Address - Phone:305-308-9771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000036363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily