Healthcare Provider Details

I. General information

NPI: 1639936958
Provider Name (Legal Business Name): ALEXANDRA CISNEROS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 HYDE PARK BLVD APT 104
HOUSTON TX
77006-2580
US

IV. Provider business mailing address

1410 HYDE PARK BLVD APT 104
HOUSTON TX
77006-2580
US

V. Phone/Fax

Practice location:
  • Phone: 832-231-4142
  • Fax:
Mailing address:
  • Phone: 832-231-4142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT88429
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: