Provider Demographics
NPI:1811267594
Name:MORENO, LORI ANN MENDOZA (APN)
Entity type:Individual
Prefix:MRS
First Name:LORI ANN
Middle Name:MENDOZA
Last Name:MORENO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 REVERE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1563
Mailing Address - Country:US
Mailing Address - Phone:224-306-1879
Mailing Address - Fax:
Practice Address - Street 1:60 REVERE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1563
Practice Address - Country:US
Practice Address - Phone:224-306-1879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009279363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health