Provider Demographics
NPI:1609539188
Name:MOFFETT, GRACE TREGRE (WHNP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:TREGRE
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 GAUSE BLVD # 101
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2244
Mailing Address - Country:US
Mailing Address - Phone:251-643-4293
Mailing Address - Fax:
Practice Address - Street 1:9954 LAKE FOREST BLVD STE 10
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-2647
Practice Address - Country:US
Practice Address - Phone:504-241-0105
Practice Address - Fax:504-241-0106
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-088498363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health