Provider Demographics
NPI:1417188558
Name:MOORE, TRACY C (APRN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:C
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:A
Other - Last Name:CAVANAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:830 S LIMESTONE STREET
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0001
Mailing Address - Country:US
Mailing Address - Phone:859-218-3206
Mailing Address - Fax:859-257-2625
Practice Address - Street 1:830 S LIMESTONE STREET
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-2477
Practice Address - Country:US
Practice Address - Phone:859-218-3247
Practice Address - Fax:859-257-2625
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1066578163W00000X
KY3006134363L00000X, 363LF0000X
FLARNP9370360363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1066578OtherRN LICENSE NUMBER
KY7100087960Medicaid
FLARNP9370360OtherRN/ARNP LICENSE
KYP400031549Medicare PIN
KY6134POtherARNP LICENSE