=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225570005
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACI MOORE APRN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2016
-----------------------------------------------------
Last Update Date | 12/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3931 N STOCKTON HILL RD
-----------------------------------------------------
City | KINGMAN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86409-2426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-385-7100
-----------------------------------------------------
Fax | 855-538-3114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3931 N STOCKTON HILL RD
-----------------------------------------------------
City | KINGMAN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86409-2426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-385-7100
-----------------------------------------------------
Fax | 855-538-3114
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | RNP315038
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 315038
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | RN186954
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN186954
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------