Provider Demographics
NPI:1346712783
Name:SANTOS, ELIZABETH DIZON (AGNP-C)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:DIZON
Last Name:SANTOS
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:MRS
Other - First Name:ELIZABETH
Other - Middle Name:SANTOS
Other - Last Name:VALERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:425 CHALAN SAN ANTONIO
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3602
Mailing Address - Country:US
Mailing Address - Phone:671-688-2623
Mailing Address - Fax:
Practice Address - Street 1:655 HARMON LOOP RD STE 300
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-6544
Practice Address - Country:US
Practice Address - Phone:671-647-5355
Practice Address - Fax:671-649-0404
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUNP0196363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health