Healthcare Provider Details

I. General information

NPI: 1912587890
Provider Name (Legal Business Name): JULIE A CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 KOSTORYZ RD
CORPUS CHRISTI TX
78415-5021
US

IV. Provider business mailing address

4444 KOSTORYZ RD
CORPUS CHRISTI TX
78415-5021
US

V. Phone/Fax

Practice location:
  • Phone: 361-855-6121
  • Fax:
Mailing address:
  • Phone: 361-855-6121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number296074
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: