Basic Information
| Provider Information | |||||||||
| NPI: | 1396098562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CUSICK | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4004 BEYER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN YSIDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921732007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
| FaxNumber: | 6194287952 | ||||||||
| Practice Location | |||||||||
| Address1: | 1552 NIGHTFALL LN | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919151950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195182438 | ||||||||
| FaxNumber: | 6194287952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2012 | ||||||||
| LastUpdateDate: | 04/18/2016 | ||||||||
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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 | 363L00000X | 599565 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | 22468 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1396098562 | 01 | CA | NPI NUMBER | OTHER | 22468 | 01 | CA | NURSE PRACTITIONER FURNISHING/ CERTITFICATE | OTHER | 599565 | 01 | CA | MEDICAL LICENSE | OTHER |