Healthcare Provider Details

I. General information

NPI: 1497941496
Provider Name (Legal Business Name): LAURIE MOODY-TIDCOMBE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 ENGLISH CREEK AVE SUITE 222
EGG HARBOR TOWNSHIP NJ
08234-5549
US

IV. Provider business mailing address

2500 ENGLISH CREEK AVE SUITE 222
EGG HARBOR TOWNSHIP NJ
08234-5549
US

V. Phone/Fax

Practice location:
  • Phone: 609-407-2365
  • Fax: 609-407-2364
Mailing address:
  • Phone: 609-407-2365
  • Fax: 609-407-2364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00143100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: