Provider Demographics
NPI:1316471535
Name:MORENO, NICOLE ANTONIA (CRNA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANTONIA
Last Name:MORENO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67000, DEPT 272801
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48264-0001
Mailing Address - Country:US
Mailing Address - Phone:517-205-4963
Mailing Address - Fax:
Practice Address - Street 1:205 NORTH EAST AVENUE
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201
Practice Address - Country:US
Practice Address - Phone:517-205-4963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704289793367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered