Healthcare Provider Details

I. General information

NPI: 1730393893
Provider Name (Legal Business Name): TRACY LYNN HUTSON MOORE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 S 16TH ST
WILMINGTON NC
28401-6491
US

IV. Provider business mailing address

PO BOX 15109
WILMINGTON NC
28408-5109
US

V. Phone/Fax

Practice location:
  • Phone: 910-393-2525
  • Fax: 910-393-2827
Mailing address:
  • Phone: 910-392-2525
  • Fax: 910-392-2827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024164830
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number900315
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: