Healthcare Provider Details

I. General information

NPI: 1629774567
Provider Name (Legal Business Name): STACIA LARK MORENO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 DIVISION ST
BALTIMORE MD
21217-3121
US

IV. Provider business mailing address

7789 ARUNDEL MILLS BLVD APT 311
HANOVER MD
21076-2020
US

V. Phone/Fax

Practice location:
  • Phone: 410-383-8300
  • Fax:
Mailing address:
  • Phone: 443-600-4886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR225927
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: