Healthcare Provider Details

I. General information

NPI: 1447986880
Provider Name (Legal Business Name): ALICIA R SISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9301 INDIAN SCHOOL RD NE STE 200D
ALBUQUERQUE NM
87112-2877
US

IV. Provider business mailing address

9301 INDIAN SCHOOL RD NE STE 200D
ALBUQUERQUE NM
87112-2877
US

V. Phone/Fax

Practice location:
  • Phone: 505-216-6469
  • Fax: 505-216-5154
Mailing address:
  • Phone: 505-216-6469
  • Fax: 505-216-5154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number958
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: