Provider Demographics
NPI:1427442268
Name:CRUZ, YESSENIA
Entity type:Individual
Prefix:
First Name:YESSENIA
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 E GILBERT ST BLDG H
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-1003
Mailing Address - Country:US
Mailing Address - Phone:909-763-4760
Mailing Address - Fax:
Practice Address - Street 1:780 E GILBERT ST BLDG H
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415
Practice Address - Country:US
Practice Address - Phone:909-763-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA743036518OtherMEDICAL