Provider Demographics
NPI:1710528930
Name:MORENO, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:23675 DORCAS LN
Mailing Address - Street 2:
Mailing Address - City:NUEVO
Mailing Address - State:CA
Mailing Address - Zip Code:92567-9722
Mailing Address - Country:US
Mailing Address - Phone:714-856-6653
Mailing Address - Fax:
Practice Address - Street 1:23880 SCARLET OAK DR
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5084
Practice Address - Country:US
Practice Address - Phone:714-856-6653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider