Provider Demographics
NPI:1356198162
Name:MORENO, STEFFANY AILYN (DO)
Entity type:Individual
Prefix:
First Name:STEFFANY
Middle Name:AILYN
Last Name:MORENO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:215-291-2500
Mailing Address - Fax:215-291-2587
Practice Address - Street 1:1412 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-2908
Practice Address - Country:US
Practice Address - Phone:215-291-2500
Practice Address - Fax:215-291-2587
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOT023712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program