Provider Demographics
NPI:1851042089
Name:MORENO, ASHLEY ANN
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ANN
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 1:855 ILLINI DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SILVIS
Mailing Address - State:IL
Mailing Address - Zip Code:61282-2904
Mailing Address - Country:US
Mailing Address - Phone:309-281-2060
Mailing Address - Fax:
Practice Address - Street 1:855 ILLINI DR STE 300
Practice Address - Street 2:
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282-2904
Practice Address - Country:US
Practice Address - Phone:309-281-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.024330363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner