Provider Demographics
NPI:1689397028
Name:LLACA-MORENO, MARIA FERNANDA
Entity Type:Individual
Prefix:
First Name:MARIA FERNANDA
Middle Name:
Last Name:LLACA-MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIA FERNANDA
Other - Middle Name:
Other - Last Name:LLACA HERRERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FMG
Mailing Address - Street 1:11631 CEDAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-5025
Mailing Address - Country:US
Mailing Address - Phone:832-896-8206
Mailing Address - Fax:
Practice Address - Street 1:11631 CEDAR CREEK DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-5025
Practice Address - Country:US
Practice Address - Phone:832-896-8206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1322-P.A.363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant