Provider Demographics
NPI:1922379866
Name:MOODY, LISSETTE Y (ARNP)
Entity Type:Individual
Prefix:MS
First Name:LISSETTE
Middle Name:Y
Last Name:MOODY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 E ALTAMONTE DR STE 324
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5103
Mailing Address - Country:US
Mailing Address - Phone:407-303-3031
Mailing Address - Fax:407-303-3047
Practice Address - Street 1:661 E ALTAMONTE DR STE 324
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701
Practice Address - Country:US
Practice Address - Phone:407-303-3031
Practice Address - Fax:407-303-3047
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9253441363L00000X
FL363LA2200X363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFW1902Medicare PIN