Provider Demographics
NPI:1952107310
Name:MOODY, STACEY (RN)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1859 SAGEWOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-7718
Mailing Address - Country:US
Mailing Address - Phone:509-981-5516
Mailing Address - Fax:
Practice Address - Street 1:1550 GEORGE WASHINGTON WAY
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-2602
Practice Address - Country:US
Practice Address - Phone:509-975-0432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANS60049955163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool