Basic Information
| Provider Information | |||||||||
| NPI: | 1326402678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORONES | ||||||||
| FirstName: | SYLVIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCABA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DRAPER | ||||||||
| OtherFirstName: | SYLVIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BCABA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6060 N COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462201907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175845166 | ||||||||
| FaxNumber: | 3178153861 | ||||||||
| Practice Location | |||||||||
| Address1: | 12912 COLDWATER RD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468458870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602451455 | ||||||||
| FaxNumber: | 3178153861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2016 | ||||||||
| LastUpdateDate: | 03/20/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | Y |
No ID Information.