Provider Demographics
NPI:1003509373
Name:SANTIAGO, CARMEN (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5306
Mailing Address - Country:US
Mailing Address - Phone:817-310-1100
Mailing Address - Fax:817-310-1197
Practice Address - Street 1:1110 N CARROLL AVE
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5306
Practice Address - Country:US
Practice Address - Phone:817-310-1100
Practice Address - Fax:817-310-1197
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1120700363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care