Provider Demographics
NPI:1770700585
Name:MOODY, SHIRLEY (PA)
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:5414 WOODARD SCHOOL ROAD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-4548
Mailing Address - Country:US
Mailing Address - Phone:618-548-0405
Mailing Address - Fax:217-253-4238
Practice Address - Street 1:625 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:TUSCOLA
Practice Address - State:IL
Practice Address - Zip Code:61953-7505
Practice Address - Country:US
Practice Address - Phone:217-253-1235
Practice Address - Fax:217-253-4238
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085-002240363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant