Individual
KACIE JO COSTELLO MOODY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
704 GOLD HILL RD, SUITE 1200, FORT MILL, SC 29715-8906
(704) 667-3380
(704) 667-3381
Mailing address
PO BOX 602148, CHARLOTTE, NC 28260-2148
(704) 667-3380
(704) 667-3381
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
0010-00779
NC
363A00000X
Physician Assistant
Primary
1295
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0640PA
—
SC
05
—
1841461373
—
NC
Enumeration date
03/12/2008
Last updated
07/21/2022
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