Healthcare Provider Details

I. General information

NPI: 1174210843
Provider Name (Legal Business Name): YAZMIN J. CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2023
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4423 W SUNNYSIDE AVE
GLENDALE AZ
85304-3509
US

IV. Provider business mailing address

4423 W SUNNYSIDE AVE
GLENDALE AZ
85304-3509
US

V. Phone/Fax

Practice location:
  • Phone: 480-798-7288
  • Fax:
Mailing address:
  • Phone: 480-798-7288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT19440
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: