Healthcare Provider Details

I. General information

NPI: 1679807275
Provider Name (Legal Business Name): ANNETTE B. MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 W 57TH ST
NEW YORK NY
10019-2929
US

IV. Provider business mailing address

521 W 57TH ST
NEW YORK NY
10019-2929
US

V. Phone/Fax

Practice location:
  • Phone: 212-698-0300
  • Fax: 212-314-8608
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number010754
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: