Provider Demographics
NPI:1033982053
Name:MOORE, TRACY RENE (LPN,CSFA)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:RENE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN,CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MARILYN DR
Mailing Address - Street 2:
Mailing Address - City:NEW BADEN
Mailing Address - State:IL
Mailing Address - Zip Code:62265-1103
Mailing Address - Country:US
Mailing Address - Phone:618-698-3620
Mailing Address - Fax:
Practice Address - Street 1:1404 CROSS ST
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2988
Practice Address - Country:US
Practice Address - Phone:618-607-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043116387164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse