Provider Demographics
NPI:1629774567
Name:MORENO, STACIA LARK (NP)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:LARK
Last Name:MORENO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7789 ARUNDEL MILLS BLVD APT 311
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-2020
Mailing Address - Country:US
Mailing Address - Phone:443-600-4886
Mailing Address - Fax:
Practice Address - Street 1:1501 DIVISION ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-3121
Practice Address - Country:US
Practice Address - Phone:410-383-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR225927363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily