Healthcare Provider Details

I. General information

NPI: 1912621384
Provider Name (Legal Business Name): NANCY CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15405 LANSDOWNE RD
TUSTIN CA
92782-0200
US

IV. Provider business mailing address

4358 MAXSON RD
EL MONTE CA
91732-2048
US

V. Phone/Fax

Practice location:
  • Phone: 714-566-8432
  • Fax:
Mailing address:
  • Phone: 714-658-5992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAII051470218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: