=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083409155
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMA LAYNE MOODY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2025
-----------------------------------------------------
Last Update Date | 04/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10543 S CRATER RD
-----------------------------------------------------
City | SOUTH PRINCE GEORGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23805-7333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-805-6989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1104 CLIFTON DR
-----------------------------------------------------
City | COLONIAL HEIGHTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834-2202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | 1401216193
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------