Provider Demographics
NPI:1871264838
Name:MOODIE, ICILDA
Entity type:Individual
Prefix:
First Name:ICILDA
Middle Name:
Last Name:MOODIE
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 1:5284 MARLBORO PIKE APT 201
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-5447
Mailing Address - Country:US
Mailing Address - Phone:240-743-0589
Mailing Address - Fax:
Practice Address - Street 1:820 UPSHUR ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5837
Practice Address - Country:US
Practice Address - Phone:202-723-0304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA200001348374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide