Provider Demographics
NPI:1447885405
Name:CISNEROS, DEBORRAH CAROLINE (HEALTH&WELLNESSCOACH)
Entity type:Individual
Prefix:MRS
First Name:DEBORRAH
Middle Name:CAROLINE
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:HEALTH&WELLNESSCOACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 AMERICAS WAY PMB18056
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:SD
Mailing Address - Zip Code:57719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17298 WOMBLE MILL RD
Practice Address - Street 2:
Practice Address - City:ZUNI
Practice Address - State:VA
Practice Address - Zip Code:23898-3543
Practice Address - Country:US
Practice Address - Phone:912-441-6288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN165950163WC1500X
CA270559322171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0000OtherN/A