Provider Demographics
NPI:1366159444
Name:MORENO, JERRICA NICOLE (MSN, FNP-BC)
Entity type:Individual
Prefix:
First Name:JERRICA
Middle Name:NICOLE
Last Name:MORENO
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 RAMAPO RD APT J
Mailing Address - Street 2:
Mailing Address - City:GARNERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10923-1851
Mailing Address - Country:US
Mailing Address - Phone:845-300-0571
Mailing Address - Fax:
Practice Address - Street 1:209 RAMAPO RD APT J
Practice Address - Street 2:
Practice Address - City:GARNERVILLE
Practice Address - State:NY
Practice Address - Zip Code:10923-1851
Practice Address - Country:US
Practice Address - Phone:845-300-0571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2021083885363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty