Healthcare Provider Details

I. General information

NPI: 1558192765
Provider Name (Legal Business Name): LUCY P CISNEROS RN, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4630 S LAKESHORE DR APT 176
TEMPE AZ
85282-7174
US

IV. Provider business mailing address

2140 E PEBBLE RD STE 250
LAS VEGAS NV
89123-3237
US

V. Phone/Fax

Practice location:
  • Phone: 480-522-7954
  • Fax: 877-211-6856
Mailing address:
  • Phone: 702-614-1149
  • Fax: 877-211-6856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN127821
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: