MEDICARE: MRS. MARIE ELLA MOODY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide		VA

General Provider Information

NPI Number	:	1962858647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARIE ELLA MOODY

Provider Business Mailing Address
First Line	:	4343 GASBURG ROAD
Second Line	:
City	:	GASBURG
State	:	VA
Zip	:	23857-2207
Country	:	US
Telephone Number	:	434-577-9072
Fax Number	:

Provider Business Practice Location Address
First Line	:	4343 GASBURG RD
Second Line	:
City	:	GASBURG
State	:	VA
Zip	:	23857-2207
Country	:	US
Telephone Number	:	434-577-9072
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2016
Last Update Date	:	05/11/2016

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