Provider Demographics
NPI:1285330654
Name:STEVENS SANTIAGO, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:STEVENS SANTIAGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SANTIAGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:646 SAINT MARKS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-3605
Mailing Address - Country:US
Mailing Address - Phone:646-358-7331
Mailing Address - Fax:
Practice Address - Street 1:646 SAINT MARKS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-3605
Practice Address - Country:US
Practice Address - Phone:646-358-7331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY426166174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist