Provider Demographics
NPI:1407242811
Name:LORI ANN MORENO APN LLC
Entity Type:Organization
Organization Name:LORI ANN MORENO APN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADVANCED PRACTICE NURSE
Authorized Official - Prefix:
Authorized Official - First Name:LORI ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC, APN
Authorized Official - Phone:224-306-1879
Mailing Address - Street 1:512 N EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2104
Mailing Address - Country:US
Mailing Address - Phone:224-770-0705
Mailing Address - Fax:
Practice Address - Street 1:60 REVERE DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1590
Practice Address - Country:US
Practice Address - Phone:224-306-1879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009279363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty