Provider Demographics
NPI:1396343430
Name:MORENO, ILKA MAYELA (CNP)
Entity type:Individual
Prefix:
First Name:ILKA
Middle Name:MAYELA
Last Name:MORENO
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3020 E CAMELBACK RD STE 301
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4418
Mailing Address - Country:US
Mailing Address - Phone:602-264-9100
Mailing Address - Fax:602-264-9101
Practice Address - Street 1:13640 N 99TH AVE STE 600
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-2867
Practice Address - Country:US
Practice Address - Phone:623-972-2116
Practice Address - Fax:623-972-0521
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ245453363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily