Provider Demographics
NPI:1083178222
Name:MORENO, MELISSA MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:MORENO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11562 CEDAR WAY
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3604
Mailing Address - Country:US
Mailing Address - Phone:218-242-1100
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST RM A504
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-7811
Practice Address - Fax:909-558-0180
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA124966367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered