Provider Demographics
NPI:1902412364
Name:MORENO, NEVRA LORRAINE
Entity Type:Individual
Prefix:
First Name:NEVRA
Middle Name:LORRAINE
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 1:4406 E SHETLAND DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-3135
Mailing Address - Country:US
Mailing Address - Phone:602-641-1190
Mailing Address - Fax:
Practice Address - Street 1:4406 E SHETLAND DR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-3135
Practice Address - Country:US
Practice Address - Phone:602-641-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-25634225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMT-25634OtherARIZONA STATE BOARD OF MASSAGE