Provider Demographics
NPI:1194773648
Name:MOODY, SUSAN E (APRN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:MOODY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:E
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:1425 HIGHWAY 34 E
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1323
Mailing Address - Country:US
Mailing Address - Phone:770-304-3724
Mailing Address - Fax:770-304-3726
Practice Address - Street 1:2101 NEWNAN CROSSING BLVD E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265
Practice Address - Country:US
Practice Address - Phone:678-552-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN189877363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBLWQMedicare PIN
P36920Medicare UPIN