Healthcare Provider Details

I. General information

NPI: 1891193744
Provider Name (Legal Business Name): MARY CATHERINE MOODY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 SW CEDAR HILLS BLVD STE 200
BEAVERTON OR
97005-1435
US

IV. Provider business mailing address

2418 W MAIN ST
GUN BARREL CITY TX
75156-3638
US

V. Phone/Fax

Practice location:
  • Phone: 503-214-1697
  • Fax:
Mailing address:
  • Phone: 903-713-2000
  • Fax: 903-713-2004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP126911
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10041565
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: