Healthcare Provider Details

I. General information

NPI: 1548191521
Provider Name (Legal Business Name): REBECCA MOODY RN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 QUANTRELLE AVE NE STE 200
OTSEGO MN
55330-1041
US

IV. Provider business mailing address

9000 QUANTRELLE AVE NE STE 200
OTSEGO MN
55330-1041
US

V. Phone/Fax

Practice location:
  • Phone: 763-633-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number2291943
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: