Provider Demographics
NPI:1508206061
Name:CISNEROS, AMALIA (ND)
Entity Type:Individual
Prefix:DR
First Name:AMALIA
Middle Name:
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 N SHARON AMITY RD STE B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-5081
Mailing Address - Country:US
Mailing Address - Phone:704-799-5815
Mailing Address - Fax:
Practice Address - Street 1:5800 N SHARON AMITY RD STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-5081
Practice Address - Country:US
Practice Address - Phone:704-799-5815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT100182174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist