Basic Information
| Provider Information | |||||||||
| NPI: | 1902847056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOODY | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | HILL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOODY | ||||||||
| OtherFirstName: | EVELYN | ||||||||
| OtherMiddleName: | SANDRA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 18868 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325238868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509945660 | ||||||||
| FaxNumber: | 8509945841 | ||||||||
| Practice Location | |||||||||
| Address1: | 6715 W HIGHWAY 98 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325065923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504536737 | ||||||||
| FaxNumber: | 8504531196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 02/23/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP1243 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | ARNP9179625 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 002421500 | 05 | FL | MEDICAID | 592-10170 | 01 | BCBSAL | OTHER | 1532321 | 05 | LA | MEDICAID | Y02EL | 01 | FL | BCBSFL | OTHER |