Provider Demographics
NPI:1962468678
Name:MOODY, CRESFIELD WINSLOW (FNP)
Entity Type:Individual
Prefix:
First Name:CRESFIELD
Middle Name:WINSLOW
Last Name:MOODY
Suffix:
Gender:M
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:PO BOX 790
Mailing Address - Street 2:463 S. LAKE POWELL BLVD
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-0790
Mailing Address - Country:US
Mailing Address - Phone:928-645-0945
Mailing Address - Fax:928-645-3254
Practice Address - Street 1:463 S. LAKE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-0790
Practice Address - Country:US
Practice Address - Phone:928-645-0945
Practice Address - Fax:925-645-3254
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2197363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ158651OtherBCBS PROVIDER NUMBER
AZAZ07272OtherELECTRONIC TRADING NUMBER
AZ957152Medicaid
AZAZ158651OtherBCBS PROVIDER NUMBER