Healthcare Provider Details

I. General information

NPI: 1528698578
Provider Name (Legal Business Name): KATIE LYNN MOODY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD STREET BOYER PAVILION - CARDIAC SURGERY
PHILADELPHIA PA
19140
US

IV. Provider business mailing address

3401 N BROAD STREET BOYER PAVILION - CARDIAC SURGERY
PHILADELPHIA PA
19140
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-2000
  • Fax:
Mailing address:
  • Phone: 215-707-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP021337
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: