Healthcare Provider Details

I. General information

NPI: 1063816015
Provider Name (Legal Business Name): MARTINIQUE N CISNEROS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 S OAKS AVE
ONTARIO CA
91762-4732
US

IV. Provider business mailing address

826 S OAKS AVE
ONTARIO CA
91762-4732
US

V. Phone/Fax

Practice location:
  • Phone: 909-247-5842
  • Fax:
Mailing address:
  • Phone: 909-247-5842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number740538
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: