Healthcare Provider Details

I. General information

NPI: 1407242811
Provider Name (Legal Business Name): LORI ANN MORENO APN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 REVERE DR STE 100
NORTHBROOK IL
60062-1590
US

IV. Provider business mailing address

512 N EMERSON ST
MOUNT PROSPECT IL
60056-2104
US

V. Phone/Fax

Practice location:
  • Phone: 224-306-1879
  • Fax:
Mailing address:
  • Phone: 224-770-0705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209009279
License Number StateIL

VIII. Authorized Official

Name: LORI ANN MORENO
Title or Position: ADVANCED PRACTICE NURSE
Credential: PMHNP-BC, APN
Phone: 224-306-1879