Provider Demographics
NPI:1053190983
Name:MOODY, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MOODY
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 1:21568 E COUNTY ROAD 400 S
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47283-9400
Mailing Address - Country:US
Mailing Address - Phone:812-390-1335
Mailing Address - Fax:
Practice Address - Street 1:3840 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-2645
Practice Address - Country:US
Practice Address - Phone:727-485-3219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INCNA09035873747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty