Provider Demographics
NPI:1306940549
Name:SANTIMORE, DONNA R (PMHCNS - BC)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:R
Last Name:SANTIMORE
Suffix:
Gender:F
Credentials:PMHCNS - BC
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:R
Other - Last Name:TULLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHCNS
Mailing Address - Street 1:40 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-3361
Mailing Address - Country:US
Mailing Address - Phone:978-534-6116
Mailing Address - Fax:978-534-3294
Practice Address - Street 1:40 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453
Practice Address - Country:US
Practice Address - Phone:978-534-6116
Practice Address - Fax:978-534-3294
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150095364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP79892Medicare UPIN
MATU NS0670Medicare ID - Type UnspecifiedPROVIDER ID NUMBER