Provider Demographics
NPI:1407136773
Name:MOORE, STACY CATHRYN (FNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:CATHRYN
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:VA
Mailing Address - Zip Code:24084-3211
Mailing Address - Country:US
Mailing Address - Phone:540-674-8805
Mailing Address - Fax:540-674-8670
Practice Address - Street 1:118 BROAD ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:VA
Practice Address - Zip Code:24084-3211
Practice Address - Country:US
Practice Address - Phone:540-674-8804
Practice Address - Fax:540-678-8670
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169559363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily