Healthcare Provider Details

I. General information

NPI: 1477547511
Provider Name (Legal Business Name): CHRISTOPHER WARD MOODY CPNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHRISTOPHER WARD MOODY CPNP

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 MAIN ST
WATERTOWN CT
06795-2260
US

IV. Provider business mailing address

380 MAIN ST
WATERTOWN CT
06795-2260
US

V. Phone/Fax

Practice location:
  • Phone: 860-274-8891
  • Fax: 860-274-8895
Mailing address:
  • Phone: 860-274-8891
  • Fax: 860-274-8895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number001457
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: