Provider Demographics
NPI:1801504477
Name:MOODY, LAUREN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARIE
Last Name:MOODY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34990
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-0627
Mailing Address - Country:US
Mailing Address - Phone:610-359-5672
Mailing Address - Fax:
Practice Address - Street 1:1203 LANGHORNE NEWTOWN RD STE 335
Practice Address - Street 2:
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-1236
Practice Address - Country:US
Practice Address - Phone:215-741-2707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-11
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00659800363A00000X
PAMA064842363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant