Provider Demographics
NPI:1891193744
Name:MOODY, MARY CATHERINE (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:MOODY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GUN BARREL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75156-3638
Mailing Address - Country:US
Mailing Address - Phone:903-713-2000
Mailing Address - Fax:903-713-2004
Practice Address - Street 1:2418 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-3638
Practice Address - Country:US
Practice Address - Phone:903-713-2000
Practice Address - Fax:903-713-2004
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126911363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily