Provider Demographics
NPI:1497149173
Name:MORENO, KATIE (CRNA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
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 1:6810 N ORIOLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1134
Mailing Address - Country:US
Mailing Address - Phone:773-425-9566
Mailing Address - Fax:
Practice Address - Street 1:1500 S CALIFORNIA AVE
Practice Address - Street 2:OS-251
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608
Practice Address - Country:US
Practice Address - Phone:773-257-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010917367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered