Provider Demographics
NPI:1215753264
Name:MOODY, DIANNE
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:
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 1:412 HIGHWAY 90 STE 11
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-3534
Mailing Address - Country:US
Mailing Address - Phone:228-304-2880
Mailing Address - Fax:
Practice Address - Street 1:412 HIGHWAY 90 STE 11
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-3534
Practice Address - Country:US
Practice Address - Phone:228-304-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1456198253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care