Healthcare Provider Details

I. General information

NPI: 1740600121
Provider Name (Legal Business Name): LETICIA MARIE CISNEROS R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 MOUNTAIN VIEW AVE
LONGMONT CO
80501-3129
US

IV. Provider business mailing address

1703 WHITEHALL DR UNIT 2E
LONGMONT CO
80504-2545
US

V. Phone/Fax

Practice location:
  • Phone: 303-651-5332
  • Fax:
Mailing address:
  • Phone: 719-331-8105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17727
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number32054
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number35293
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: