Provider Demographics
NPI:1053636613
Name:LANGE, TRACY M (MSN, FNP, PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:M
Last Name:LANGE
Suffix:
Gender:F
Credentials:MSN, FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22280 JEB STUART HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:VA
Mailing Address - Zip Code:24171-2999
Mailing Address - Country:US
Mailing Address - Phone:276-694-4361
Mailing Address - Fax:276-629-2695
Practice Address - Street 1:22280 JEB STUART HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171-2999
Practice Address - Country:US
Practice Address - Phone:276-694-4361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168745363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily