Provider Demographics
NPI:1447977202
Name:MOODY, KYLEE ELISE
Entity type:Individual
Prefix:MISS
First Name:KYLEE
Middle Name:ELISE
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 1:4291 N STATE ROAD 157
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:47424-6553
Mailing Address - Country:US
Mailing Address - Phone:812-381-3444
Mailing Address - Fax:
Practice Address - Street 1:1400 S GERMANTOWN RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2205
Practice Address - Country:US
Practice Address - Phone:901-759-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6368363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant