Provider Demographics
NPI:1982219697
Name:MORENO, LAURA (APRN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1632 CAMDEN WAY # X
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-2939
Mailing Address - Country:US
Mailing Address - Phone:405-926-0353
Mailing Address - Fax:
Practice Address - Street 1:1534 E. 15TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3630
Practice Address - Country:US
Practice Address - Phone:405-861-0224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK115206207Q00000X
OK200085363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty