Provider Demographics
NPI:1790343531
Name:MORENO, AMANDA LYNN (LVN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:MORENO
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 LOUETTA RD APT 5204
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77388-4871
Mailing Address - Country:US
Mailing Address - Phone:832-378-0668
Mailing Address - Fax:
Practice Address - Street 1:460 WILDWOOD FOREST DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380-3884
Practice Address - Country:US
Practice Address - Phone:832-485-3793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX303430164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse