Provider Demographics
NPI:1508212796
Name:MORENO, JODY LEE
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:LEE
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3991 BRUTON RD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33565-7023
Mailing Address - Country:US
Mailing Address - Phone:813-716-9698
Mailing Address - Fax:
Practice Address - Street 1:3525 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-1965
Practice Address - Country:US
Practice Address - Phone:863-603-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9329228363LF0000X
FLAPRN9329228363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily