Provider Demographics
NPI:1902207996
Name:MOODIE, MARCIA
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
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 1:13023 218TH ST
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1232
Mailing Address - Country:US
Mailing Address - Phone:718-525-2932
Mailing Address - Fax:718-525-2932
Practice Address - Street 1:13023 218TH ST
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-1232
Practice Address - Country:US
Practice Address - Phone:718-525-2932
Practice Address - Fax:718-525-2932
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244802-1372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion