Provider Demographics
NPI:1568261360
Name:MORENO, THEDA JUANA
Entity type:Individual
Prefix:
First Name:THEDA
Middle Name:JUANA
Last Name:MORENO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4037 RANCHO DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-4048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1950 S SHEPARD AVE
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-6357
Practice Address - Country:US
Practice Address - Phone:405-549-3519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist