Healthcare Provider Details

I. General information

NPI: 1679145981
Provider Name (Legal Business Name): TRACY LOUISE MOORE DUARTE MSN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 06/07/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E HUNDRED RD STE 101
CHESTER VA
23836-3300
US

IV. Provider business mailing address

PO BOX 2998
CHESTER VA
23831-8455
US

V. Phone/Fax

Practice location:
  • Phone: 804-681-0673
  • Fax: 804-681-0675
Mailing address:
  • Phone: 804-330-8101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024182138
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5014774
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5014774
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024182138
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: