1629221692 NPI number — TRACY L MOSS FNP-C

Table of content: TRACY L MOSS FNP-C (NPI 1629221692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629221692 NPI number — TRACY L MOSS FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOSS
Provider First Name:
TRACY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629221692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1407 W BADDOUR PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37087-2513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-444-6203
Provider Business Mailing Address Fax Number:
615-444-6252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6650 EASTEGATE BLVD
Provider Second Line Business Practice Location Address:
#104
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37090-6018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-900-5451
Provider Business Practice Location Address Fax Number:
615-900-5440
Provider Enumeration Date:
11/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  13753 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RN120814 . This is a "RN LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1511933 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2994253 . This is a "UHC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4244349 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 11931653 . This is a "CAQH" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3245563 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: APN13753 . This is a "FNP LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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