Healthcare Provider Details

I. General information

NPI: 1881380889
Provider Name (Legal Business Name): MIRYAM CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 CHASE AVE
JOLIET IL
60432-1659
US

IV. Provider business mailing address

655 CHASE AVE
JOLIET IL
60432-1659
US

V. Phone/Fax

Practice location:
  • Phone: 815-630-1525
  • Fax:
Mailing address:
  • Phone: 815-630-1525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: