Healthcare Provider Details

I. General information

NPI: 1891185971
Provider Name (Legal Business Name): LORI ANN M MORENO APN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 REVERE DR SUITE 100
NORTHBROOK IL
60062-1563
US

IV. Provider business mailing address

60 REVERE DR SUITE 100
NORTHBROOK IL
60062-1563
US

V. Phone/Fax

Practice location:
  • Phone: 224-306-1879
  • Fax:
Mailing address:
  • Phone:
  • 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: MRS. LORI ANN MENDOZA MORENO
Title or Position: NURSE PRACTITIONER
Credential: APN
Phone: 224-306-1879