Provider Demographics
NPI:1376216242
Name:MORENO, EVELIN
Entity Type:Individual
Prefix:
First Name:EVELIN
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 COLONY POINT CIRCLE
Mailing Address - Street 2:APARTMENT 314 BUILDING 5
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026
Mailing Address - Country:US
Mailing Address - Phone:754-217-0977
Mailing Address - Fax:
Practice Address - Street 1:1001 COLONY POINT CIRCLE
Practice Address - Street 2:APARTMENT 314 BUILDING 5
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026
Practice Address - Country:US
Practice Address - Phone:754-217-0977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21-434390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program