Healthcare Provider Details

I. General information

NPI: 1831370303
Provider Name (Legal Business Name): MRS. ILIAM AMALIA CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY CISNEROS R.N.

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2499 E LAKESHORE DR
LAKE ELSINORE CA
92530-4446
US

IV. Provider business mailing address

4065 COUNTY CIRCLE DR
RIVERSIDE CA
92503-3410
US

V. Phone/Fax

Practice location:
  • Phone: 951-471-4224
  • Fax:
Mailing address:
  • Phone: 951-471-4224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN517135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: