Provider Demographics
NPI:1194262519
Name:MORENO, LISA (APRN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4357 CORPORATE CENTER DR STE 450
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-0226
Mailing Address - Country:US
Mailing Address - Phone:702-644-4673
Mailing Address - Fax:702-902-4453
Practice Address - Street 1:4357 CORPORATE CENTER DR STE 450
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-0226
Practice Address - Country:US
Practice Address - Phone:702-644-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN002443363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health