Provider Demographics
NPI:1992407787
Name:MOODY, CHARLOTTE
Entity type:Individual
Prefix:
First Name:CHARLOTTE
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 1:120 PAW PAW STREET BOX 303
Mailing Address - Street 2:
Mailing Address - City:GRANT TOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26574
Mailing Address - Country:US
Mailing Address - Phone:304-842-0200
Mailing Address - Fax:
Practice Address - Street 1:120 PAW PAW STREET 303
Practice Address - Street 2:
Practice Address - City:GRANT TOWN
Practice Address - State:WV
Practice Address - Zip Code:26574
Practice Address - Country:US
Practice Address - Phone:304-842-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker