Healthcare Provider Details

I. General information

NPI: 1629853858
Provider Name (Legal Business Name): KATLIN MARIAH MOODY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44453 16TH ST W STE 101
LANCASTER CA
93534-2883
US

IV. Provider business mailing address

9001 STOCKDALE HWY
BAKERSFIELD CA
93311-1022
US

V. Phone/Fax

Practice location:
  • Phone: 661-816-1330
  • Fax:
Mailing address:
  • Phone: 661-654-2505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95035418
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: