Provider Demographics
NPI:1093919276
Name:CISNEROS-RIVAS, CAROL (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:CISNEROS-RIVAS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N STATE ST RM 10850 A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1029
Mailing Address - Country:US
Mailing Address - Phone:323-226-7655
Mailing Address - Fax:323-229-5996
Practice Address - Street 1:1200 N STATE ST RM 10850 A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:323-226-7655
Practice Address - Fax:323-229-5996
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 301799363L00000X
CA301799363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner