Provider Demographics
NPI:1740990415
Name:MOODY, AUDREY (PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9422 COPPERWAY
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-2063
Mailing Address - Country:US
Mailing Address - Phone:210-322-0191
Mailing Address - Fax:
Practice Address - Street 1:9422 COPPERWAY
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109-2063
Practice Address - Country:US
Practice Address - Phone:210-322-0191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1099816363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty