Provider Demographics
NPI:1891185971
Name:LORI ANN M MORENO APN LLC
Entity Type:Organization
Organization Name:LORI ANN M MORENO APN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI ANN
Authorized Official - Middle Name:MENDOZA
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:224-306-1879
Mailing Address - Street 1:60 REVERE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 REVERE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1563
Practice Address - Country:US
Practice Address - Phone:224-306-1879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-28
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009279363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty