Provider Demographics
NPI:1639193899
Name:MOODY, NANCY (PA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4281 OLD NINE FOOT ROAD
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:33829
Mailing Address - Country:US
Mailing Address - Phone:863-294-9223
Mailing Address - Fax:727-507-3618
Practice Address - Street 1:1324 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4543
Practice Address - Country:US
Practice Address - Phone:863-687-1132
Practice Address - Fax:863-687-1439
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2377363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P19601Medicare UPIN