Healthcare Provider Details

I. General information

NPI: 1467911735
Provider Name (Legal Business Name): JAN CISNEROS-NEITH DN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2019
Last Update Date: 03/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2887 CLARK CT
SANTA FE NM
87507-5179
US

IV. Provider business mailing address

3201C ZAFARANO DR # 185
SANTA FE NM
87507-2668
US

V. Phone/Fax

Practice location:
  • Phone: 505-629-1905
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number01032
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: