Provider Demographics
NPI:1720471576
Name:MORENO, REBECCA (LVN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 DAHLIA AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2021
Mailing Address - Country:US
Mailing Address - Phone:619-971-7994
Mailing Address - Fax:
Practice Address - Street 1:730 MEDICAL CENTER CT
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6618
Practice Address - Country:US
Practice Address - Phone:619-397-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 279067164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse