Provider Demographics
NPI:1396098562
Name:MORENO, EMILY RENEE (FNP)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:RENEE
Last Name:MORENO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:RENEE
Other - Last Name:CUSICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4004 BEYER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-2007
Mailing Address - Country:US
Mailing Address - Phone:619-662-4100
Mailing Address - Fax:619-428-7952
Practice Address - Street 1:1552 NIGHTFALL LN
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91915-1950
Practice Address - Country:US
Practice Address - Phone:619-518-2438
Practice Address - Fax:619-428-7952
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1678229163W00000X
CA599565363L00000X
CO0997112-NP363LF0000X, 363LP0200X
CA22468363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1678229OtherRN
CO0106141-NPOtherRXN
CA22468OtherNURSE PRACTITIONER FURNISHING/ CERTITFICATE
CO0997112-NPOtherNURSE PRACTITIONER/APN
CA599565OtherMEDICAL LICENSE
CA1396098562OtherNPI NUMBER