Healthcare Provider Details

I. General information

NPI: 1063185932
Provider Name (Legal Business Name): JASMINE CISNEROS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 10/21/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17692 BEACH BLVD STE 200
HUNTINGTON BEACH CA
92647-6810
US

IV. Provider business mailing address

5782 MARSHALL AVE
BUENA PARK CA
90621-2126
US

V. Phone/Fax

Practice location:
  • Phone: 714-847-6975
  • Fax:
Mailing address:
  • Phone: 714-350-2769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number95181844
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95018913
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: