Provider Demographics
NPI:1912713462
Name:MORENO, IVY (ND)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 411
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80306-0411
Mailing Address - Country:US
Mailing Address - Phone:541-968-3633
Mailing Address - Fax:
Practice Address - Street 1:1181 S PARKER RD STE 101
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-2152
Practice Address - Country:US
Practice Address - Phone:303-337-4884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000290175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath