Healthcare Provider Details

I. General information

NPI: 1114083680
Provider Name (Legal Business Name): ASHLEY TUMLIN MOODY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S RAVENEL ST SUITE 230
FLORENCE SC
29506-2618
US

IV. Provider business mailing address

PO BOX 3239
FLORENCE SC
29502-3239
US

V. Phone/Fax

Practice location:
  • Phone: 843-777-7043
  • Fax: 843-777-7041
Mailing address:
  • Phone: 843-777-7120
  • Fax: 843-777-7102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number730
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: