Provider Demographics
NPI:1275186710
Name:MORENO, DIANA L
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
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 1:13628 ASHLAR SLATE PL
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2139
Mailing Address - Country:US
Mailing Address - Phone:917-337-5480
Mailing Address - Fax:
Practice Address - Street 1:13628 ASHLAR SLATE PL
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-2139
Practice Address - Country:US
Practice Address - Phone:917-337-5480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver