Healthcare Provider Details

I. General information

NPI: 1700252822
Provider Name (Legal Business Name): SASHA L MOREDOCK APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

287 PARK AVE S FL 5
NEW YORK NY
10010-4573
US

IV. Provider business mailing address

5304 N WOODVIEW AVE
PEORIA IL
61614-4559
US

V. Phone/Fax

Practice location:
  • Phone: 888-553-2823
  • Fax: 857-305-0177
Mailing address:
  • Phone: 309-453-0196
  • Fax: 309-453-0196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number350128
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013058
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1016060
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: