Provider Demographics
NPI:1548058571
Name:MOODY, BRANDY NICOLE
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:NICOLE
Last Name:MOODY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1822
Mailing Address - Country:US
Mailing Address - Phone:220-564-4918
Mailing Address - Fax:220-564-4918
Practice Address - Street 1:1865 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2305
Practice Address - Country:US
Practice Address - Phone:220-564-4918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH359208172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker