Provider Demographics
NPI:1144326463
Name:MOODY, HARRIET D (PA-C)
Entity type:Individual
Prefix:
First Name:HARRIET
Middle Name:D
Last Name:MOODY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4367 NEW SNAPFINGER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-2920
Mailing Address - Country:US
Mailing Address - Phone:770-981-2008
Mailing Address - Fax:770-981-6302
Practice Address - Street 1:4367 NEW SNAPFINGER WOODS DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-2920
Practice Address - Country:US
Practice Address - Phone:770-981-2008
Practice Address - Fax:770-981-6302
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003716363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA583231074AMedicaid
GAP85299Medicare UPIN
GA583231074AMedicaid