Healthcare Provider Details

I. General information

NPI: 1083178222
Provider Name (Legal Business Name): MELISSA MARIE MORENO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST RM A504
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

11562 CEDAR WAY
LOMA LINDA CA
92354-3604
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-7811
  • Fax: 909-558-0180
Mailing address:
  • Phone: 218-242-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number124966
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: