Provider Demographics
NPI:1154589547
Name:MOORE CHESTNUT, TRACY L
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:MOORE CHESTNUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41051 STATE ROUTE 517
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-9354
Mailing Address - Country:US
Mailing Address - Phone:330-271-9553
Mailing Address - Fax:330-424-4921
Practice Address - Street 1:41051 STATE ROUTE 517
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-9354
Practice Address - Country:US
Practice Address - Phone:330-271-9553
Practice Address - Fax:330-424-4921
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2784027Medicaid