Provider Demographics
NPI:1629221692
Name:MOSS, TRACY L (FNP-C)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:MOSS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 W BADDOUR PKWY
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2513
Mailing Address - Country:US
Mailing Address - Phone:615-444-6203
Mailing Address - Fax:615-444-6252
Practice Address - Street 1:6650 EASTEGATE BLVD
Practice Address - Street 2:#104
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-6018
Practice Address - Country:US
Practice Address - Phone:615-900-5451
Practice Address - Fax:615-900-5440
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13753363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNRN120814OtherRN LICENSE
TN1511933Medicaid
TN2994253OtherUHC
TN4244349OtherBCBS
TN11931653OtherCAQH
TN3245563OtherCIGNA
TNAPN13753OtherFNP LICENSE
TN3245563OtherCIGNA