Healthcare Provider Details

I. General information

NPI: 1376209486
Provider Name (Legal Business Name): MARITZA CORREA MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 N U ST
FRESNO CA
93701-2438
US

IV. Provider business mailing address

153 N U ST
FRESNO CA
93701-2438
US

V. Phone/Fax

Practice location:
  • Phone: 559-445-9094
  • Fax:
Mailing address:
  • Phone: 559-445-9094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: