Provider Demographics
NPI:1518633122
Name:MOORE, LATRICE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LATRICE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41049 INDIGO PL
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-4825
Mailing Address - Country:US
Mailing Address - Phone:703-297-2685
Mailing Address - Fax:
Practice Address - Street 1:19450 DEERFIELD AVE STE 325
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8503
Practice Address - Country:US
Practice Address - Phone:571-252-8119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182341363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner