Healthcare Provider Details

I. General information

NPI: 1306491311
Provider Name (Legal Business Name): TRACEY D MOORE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 CAMERON ST
ANSLEY NE
68814-0370
US

IV. Provider business mailing address

PO BOX 370
ANSLEY NE
68814-0370
US

V. Phone/Fax

Practice location:
  • Phone: 308-935-1121
  • Fax: 308-935-9103
Mailing address:
  • Phone: 308-935-1121
  • Fax: 308-935-9103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number56186
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: