Provider Demographics
NPI:1528590502
Name:MORENO, MISTY MARIE
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:MARIE
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 1:1 CHILDREN'S WAY
Mailing Address - Street 2:#653
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-5061
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS WAY
Practice Address - Street 2:SLOT 203
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-2938
Practice Address - Fax:501-364-2939
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPENDING367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered