Provider Demographics
NPI:1609077809
Name:MOODY, VICTORIA JOYCE (LD, MPH)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:JOYCE
Last Name:MOODY
Suffix:
Gender:F
Credentials:LD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 PALOMINO PASS
Mailing Address - Street 2:
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-2889
Mailing Address - Country:US
Mailing Address - Phone:706-583-2859
Mailing Address - Fax:706-543-2034
Practice Address - Street 1:189 PARADISE BLVD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-1121
Practice Address - Country:US
Practice Address - Phone:706-338-9185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000807132700000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education