Provider Demographics
NPI:1336707488
Name:MOODY, ELONDA (LPN)
Entity Type:Individual
Prefix:
First Name:ELONDA
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 COPELAND ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609-4737
Mailing Address - Country:US
Mailing Address - Phone:585-498-0730
Mailing Address - Fax:
Practice Address - Street 1:131 COPELAND ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-4737
Practice Address - Country:US
Practice Address - Phone:585-498-0730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334006164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY334006Medicaid