Healthcare Provider Details

I. General information

NPI: 1306829692
Provider Name (Legal Business Name): MITA MOORTHI FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 KEMPSVILLE RD STE 103B
NORFOLK VA
23502-3927
US

IV. Provider business mailing address

844 KEMPSVILLE RD STE 103B
NORFOLK VA
23502-3927
US

V. Phone/Fax

Practice location:
  • Phone: 757-261-0200
  • Fax: 757-261-0201
Mailing address:
  • Phone: 757-261-0200
  • Fax: 757-261-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number334657
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number482708-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024196850
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: