Provider Demographics
NPI:1023648243
Name:MOODIE, TASCHECKA MORVIA (AGNP)
Entity type:Individual
Prefix:
First Name:TASCHECKA
Middle Name:MORVIA
Last Name:MOODIE
Suffix:
Gender:F
Credentials:AGNP
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 303
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-0303
Mailing Address - Country:US
Mailing Address - Phone:404-256-2525
Mailing Address - Fax:
Practice Address - Street 1:5670 PEACHTREE DUNWOODY RD STE 880
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4789
Practice Address - Country:US
Practice Address - Phone:404-256-2525
Practice Address - Fax:404-256-9589
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN228769363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner