Healthcare Provider Details

I. General information

NPI: 1114402427
Provider Name (Legal Business Name): ELETHIA M MOORE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 OLD IVY WAY
CHARLOTTESVILLE VA
22903-4896
US

IV. Provider business mailing address

PO BOX 749112
ATLANTA GA
30374-9112
US

V. Phone/Fax

Practice location:
  • Phone: 434-243-6950
  • Fax:
Mailing address:
  • Phone: 434-295-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024189825
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: