Provider Demographics
NPI:1508424128
Name:MORENO, JUDY AIVETTE (CRNP-FAMILY)
Entity Type:Individual
Prefix:
First Name:JUDY AIVETTE
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:CRNP-FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4513 GINA CT
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3702
Mailing Address - Country:US
Mailing Address - Phone:410-530-5048
Mailing Address - Fax:
Practice Address - Street 1:301 SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-332-9407
Practice Address - Fax:410-332-9789
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR176392363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily