Provider Demographics
NPI:1063749885
Name:MOODY, TONYA (LVN)
Entity type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 N MIAMI AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-3519
Mailing Address - Country:US
Mailing Address - Phone:559-974-0244
Mailing Address - Fax:
Practice Address - Street 1:312 N MIAMI AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-3519
Practice Address - Country:US
Practice Address - Phone:559-974-0244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN173059164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse