Provider Demographics
NPI:1336970508
Name:MORAN, ELENA MICHELLE
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:MICHELLE
Last Name:MORAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5118 BLUEBELL AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-2912
Mailing Address - Country:US
Mailing Address - Phone:954-895-7049
Mailing Address - Fax:
Practice Address - Street 1:5118 BLUEBELL AVE
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-2912
Practice Address - Country:US
Practice Address - Phone:954-895-7049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029886363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health