Provider Demographics
NPI:1679129480
Name:MORENO, KRISTAL MARIE
Entity type:Individual
Prefix:
First Name:KRISTAL
Middle Name:MARIE
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTAL
Other - Middle Name:MARIE
Other - Last Name:BENITZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:300 MIKE LOZA DR UNIT 109
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8479
Mailing Address - Country:US
Mailing Address - Phone:805-307-6296
Mailing Address - Fax:
Practice Address - Street 1:244 E CLARA ST
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93041-2732
Practice Address - Country:US
Practice Address - Phone:805-307-6296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA689647164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXEQ9913232OtherBLUE SHIELD