Healthcare Provider Details

I. General information

NPI: 1760200331
Provider Name (Legal Business Name): MARIANNA GIOCONDA CISNEROS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4138 CHARLES ST
LA MESA CA
91941-7521
US

IV. Provider business mailing address

4138 CHARLES ST
LA MESA CA
91941-7521
US

V. Phone/Fax

Practice location:
  • Phone: 619-894-4004
  • Fax:
Mailing address:
  • Phone: 619-894-4004
  • Fax: 619-894-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95029343
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: