Provider Demographics
NPI:1295938801
Name:MOODY, KAREN ADAMS (CRNA)
Entity type:Individual
Prefix:MS
First Name:KAREN
Middle Name:ADAMS
Last Name:MOODY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 CLUB ACRES BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-4117
Mailing Address - Country:US
Mailing Address - Phone:803-268-9680
Mailing Address - Fax:803-268-9680
Practice Address - Street 1:1330 TAYLOR STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29220-0001
Practice Address - Country:US
Practice Address - Phone:803-296-5010
Practice Address - Fax:803-268-9680
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-10
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1999367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1255Medicaid