Provider Demographics
NPI:1720703267
Name:MORENO, KATLYN
Entity Type:Individual
Prefix:
First Name:KATLYN
Middle Name:
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 1:1604 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-2001
Mailing Address - Country:US
Mailing Address - Phone:626-501-2390
Mailing Address - Fax:
Practice Address - Street 1:9864 BALDWIN PL
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2202
Practice Address - Country:US
Practice Address - Phone:626-433-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator