Basic Information
| Provider Information | |||||||||
| NPI: | 1982106993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | MARIA FERNANDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LHAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6700 WASHINGTON AVE S | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123511529 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2100 E HALLANDALE BEACH BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | HALLANDALE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544581717 | ||||||||
| FaxNumber: | 9544583017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2018 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | AS5351 | FL | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | AS5351 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | AS5351 | 05 | FL | MEDICAID |