Healthcare Provider Details

I. General information

NPI: 1538046412
Provider Name (Legal Business Name): MARIAH IVORY CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

942 S ATLANTIC BLVD
LOS ANGELES CA
90022-4004
US

IV. Provider business mailing address

161 BAHIA DR
COVINA CA
91722-2862
US

V. Phone/Fax

Practice location:
  • Phone: 323-263-9700
  • Fax: 323-263-8042
Mailing address:
  • Phone: 323-263-9700
  • Fax: 323-263-8042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: