Basic Information
| Provider Information | |||||||||
| NPI: | 1053636613 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANGE | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSN, FNP, PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22280 JEB STUART HWY | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241712999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766944361 | ||||||||
| FaxNumber: | 2766292695 | ||||||||
| Practice Location | |||||||||
| Address1: | 22280 JEB STUART HWY | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241712999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766944361 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2010 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024168745 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 0024168745 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.