Provider Demographics
NPI:1124494406
Name:MOODY, GINA PAMELA
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:PAMELA
Last Name:MOODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 ELDERS DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9133
Mailing Address - Country:US
Mailing Address - Phone:706-631-3373
Mailing Address - Fax:
Practice Address - Street 1:4110 ELDERS DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9133
Practice Address - Country:US
Practice Address - Phone:706-631-3373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver