Provider Demographics
NPI:1114313673
Name:VANMALDEGHEM, SANTIANA
Entity Type:Individual
Prefix:
First Name:SANTIANA
Middle Name:
Last Name:VANMALDEGHEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 S PERRY ST STE 104B
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-1950
Mailing Address - Country:US
Mailing Address - Phone:720-485-3178
Mailing Address - Fax:720-414-0006
Practice Address - Street 1:1001 S PERRY ST STE 104B
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1950
Practice Address - Country:US
Practice Address - Phone:720-485-3178
Practice Address - Fax:720-414-0006
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-11
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0187079163W00000X
COAPN.0992794-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse