Provider Demographics
NPI:1720771611
Name:MORENO, MABEDIA (FNP)
Entity type:Individual
Prefix:
First Name:MABEDIA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 PEASE RD
Mailing Address - Street 2:
Mailing Address - City:BROAD BROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06016-9003
Mailing Address - Country:US
Mailing Address - Phone:860-983-2385
Mailing Address - Fax:
Practice Address - Street 1:1678 ASYLUM AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2764
Practice Address - Country:US
Practice Address - Phone:860-232-4571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT012192363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner