Basic Information
| Provider Information | |||||||||
| NPI: | 1316471535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ANTONIA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 67000, DEPT 272801 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482640001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172054963 | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 NORTH EAST AVENUE | ||||||||
| Address2: | ANESTHESIA DEPARTMENT | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172054963 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2017 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 4704289793 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.