Basic Information
| Provider Information | |||||||||
| NPI: | 1184766057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | ANNABEL | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 196276 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995196276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072126233 | ||||||||
| FaxNumber: | 9075633217 | ||||||||
| Practice Location | |||||||||
| Address1: | 3760 PIPER STREET | ||||||||
| Address2: | SUITE LL139 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995047459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072126233 | ||||||||
| FaxNumber: | 9075633217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 24598 | AK | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | AK | MEDICAID |