Provider Demographics
NPI:1083209183
Name:SANTIAGO LOPEZ, OLGUIMER (FNP)
Entity Type:Individual
Prefix:
First Name:OLGUIMER
Middle Name:
Last Name:SANTIAGO LOPEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 TRINITY RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-7501
Mailing Address - Country:US
Mailing Address - Phone:787-215-9141
Mailing Address - Fax:
Practice Address - Street 1:1812 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1834
Practice Address - Country:US
Practice Address - Phone:407-897-3499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11011867363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty