Provider Demographics
NPI:1982225512
Name:MORON, CHERONNA SHAUNTE'
Entity Type:Individual
Prefix:
First Name:CHERONNA
Middle Name:SHAUNTE'
Last Name:MORON
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 1:213 1/2 E 84TH PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-3027
Mailing Address - Country:US
Mailing Address - Phone:267-270-9018
Mailing Address - Fax:
Practice Address - Street 1:503 OCEAN FRONT WALK
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2403
Practice Address - Country:US
Practice Address - Phone:310-392-3070
Practice Address - Fax:310-392-0823
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN212640164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse