Provider Demographics
NPI:1649864497
Name:MORENO, LAUREL ANN
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:ANN
Last Name:MORENO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:ANN
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1155 S POWER RD STE 114-410
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3715
Mailing Address - Country:US
Mailing Address - Phone:800-402-0881
Mailing Address - Fax:
Practice Address - Street 1:1155 S POWER RD STE 114-410
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3715
Practice Address - Country:US
Practice Address - Phone:800-402-0881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN147283163W00000X
AZ259881367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse