Healthcare Provider Details

I. General information

NPI: 1447885405
Provider Name (Legal Business Name): DEBORRAH CAROLINE CISNEROS HEALTH&WELLNESSCOACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17298 WOMBLE MILL RD
ZUNI VA
23898-3543
US

IV. Provider business mailing address

514 AMERICAS WAY PMB18056
BOX ELDER SD
57719
US

V. Phone/Fax

Practice location:
  • Phone: 912-441-6288
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN165950
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number270559322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: