Provider Demographics
NPI:1962090522
Name:MORENO, ELIZABETH (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1641 BIRCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2907
Mailing Address - Country:US
Mailing Address - Phone:517-203-9059
Mailing Address - Fax:
Practice Address - Street 1:505 N CLIPPERT ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4701
Practice Address - Country:US
Practice Address - Phone:517-999-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704273355363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily