Provider Demographics
NPI:1356679914
Name:MORENO, NANCY (PTA)
Entity Type:Individual
Prefix:MISS
First Name:NANCY
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 S SOTO ST
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CA
Mailing Address - Zip Code:90058-1718
Mailing Address - Country:US
Mailing Address - Phone:323-585-7162
Mailing Address - Fax:323-585-0167
Practice Address - Street 1:11555 DAVENRICH ST
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3603
Practice Address - Country:US
Practice Address - Phone:562-233-2621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6596225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant