Provider Demographics
NPI:1104672930
Name:MORAN, SOFIA LUCINA (PMHNP)
Entity type:Individual
Prefix:
First Name:SOFIA
Middle Name:LUCINA
Last Name:MORAN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:LUCINA
Other - Middle Name:MORAN
Other - Last Name:BARTLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:473 E. CARNEGIE DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408
Mailing Address - Country:US
Mailing Address - Phone:840-252-7774
Mailing Address - Fax:840-223-5913
Practice Address - Street 1:473 E. CARNEGIE DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408
Practice Address - Country:US
Practice Address - Phone:840-252-7774
Practice Address - Fax:840-223-5913
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029887363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty