Healthcare Provider Details

I. General information

NPI: 1568410140
Provider Name (Legal Business Name): VICKY JO MORAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICKY JO MORAN BAKER CRNA

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 E CORONADO RD
PHOENIX AZ
85004-1525
US

IV. Provider business mailing address

349 E CORONADO RD
PHOENIX AZ
85004-1525
US

V. Phone/Fax

Practice location:
  • Phone: 602-266-5678
  • Fax:
Mailing address:
  • Phone: 602-266-5678
  • Fax: 770-559-1231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN103578
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number251502
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: