Healthcare Provider Details

I. General information

NPI: 1134255748
Provider Name (Legal Business Name): BRENDA K. MOODY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8110 COUNTY ROAD 44 LEG A
LEESBURG FL
34788-3704
US

IV. Provider business mailing address

8110 COUNTY ROAD 44 LEG A
LEESBURG FL
34788-3704
US

V. Phone/Fax

Practice location:
  • Phone: 352-323-8868
  • Fax: 352-323-8865
Mailing address:
  • Phone: 352-323-8868
  • Fax: 352-323-8865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP 9335818
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: