Provider Demographics
NPI:1043881956
Name:GRIDER, TRACIE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:GRIDER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:
Other - Last Name:GRIDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:961 OLMSTEAD ST
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-1463
Mailing Address - Country:US
Mailing Address - Phone:757-319-7202
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:757-953-0609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001192036163WC0400X
VA2020146276363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management