Provider Demographics
NPI:1306061700
Name:CENICEROS, KELLY MICHELLE (RN)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MICHELLE
Last Name:CENICEROS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615-0038
Mailing Address - Country:US
Mailing Address - Phone:520-366-5508
Mailing Address - Fax:520-366-5592
Practice Address - Street 1:6849 E. HWY 92
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:AZ
Practice Address - Zip Code:85615-0038
Practice Address - Country:US
Practice Address - Phone:520-366-5508
Practice Address - Fax:520-366-5592
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN115568163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ636045Medicaid