Provider Demographics
NPI:1528611712
Name:SANTISTEVAN, SHANA SE'RAE (FNP)
Entity type:Individual
Prefix:MS
First Name:SHANA
Middle Name:SE'RAE
Last Name:SANTISTEVAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:SHANA
Other - Middle Name:SE'RAE
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:20400 MARKETPLACE AVE APT 184
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-6627
Mailing Address - Country:US
Mailing Address - Phone:719-469-3003
Mailing Address - Fax:
Practice Address - Street 1:6565 WEST LOOP S STE 525
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-3519
Practice Address - Country:US
Practice Address - Phone:713-661-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1032762363LF0000X
CO0201923163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health