Healthcare Provider Details

I. General information

NPI: 1265950190
Provider Name (Legal Business Name): KIMBERLY N CISNEROS LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 08/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 N RESERVOIR ST
LANCASTER PA
17602-2447
US

IV. Provider business mailing address

1031 W MAIN ST APT L
MOUNT JOY PA
17552-9773
US

V. Phone/Fax

Practice location:
  • Phone: 717-587-3497
  • Fax:
Mailing address:
  • Phone: 717-623-3180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT005560
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: