Provider Demographics
NPI:1679145981
Name:MOORE DUARTE, TRACY LOUISE (MSN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LOUISE
Last Name:MOORE DUARTE
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2998
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-8455
Mailing Address - Country:US
Mailing Address - Phone:804-330-8101
Mailing Address - Fax:
Practice Address - Street 1:1720 E HUNDRED RD STE 101
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23836-3300
Practice Address - Country:US
Practice Address - Phone:804-681-0673
Practice Address - Fax:804-681-0675
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182138363L00000X, 363LP0808X
NC5014774363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner