Provider Demographics
NPI:1891178653
Name:LANDRY MORENO, NICOLE LEANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LEANNE
Last Name:LANDRY MORENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:LEANNE
Other - Last Name:LANDRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1718 E KESSLER BLVD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-1842
Mailing Address - Country:US
Mailing Address - Phone:603-747-5800
Mailing Address - Fax:360-575-3846
Practice Address - Street 1:1718 E KESSLER BLVD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-1842
Practice Address - Country:US
Practice Address - Phone:360-747-5800
Practice Address - Fax:360-575-3846
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5875 - 851207Q00000X
WAMD60855874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine