Healthcare Provider Details

I. General information

NPI: 1306061700
Provider Name (Legal Business Name): KELLY MICHELLE CENICEROS R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6849 E. HWY 92
HEREFORD AZ
85615-0038
US

IV. Provider business mailing address

PO BOX 38
HEREFORD AZ
85615-0038
US

V. Phone/Fax

Practice location:
  • Phone: 520-366-5508
  • Fax: 520-366-5592
Mailing address:
  • Phone: 520-366-5508
  • Fax: 520-366-5592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN115568
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: