Provider Demographics
NPI:1114571312
Name:SANTIAGO, TASHIA MARIE
Entity Type:Individual
Prefix:
First Name:TASHIA
Middle Name:MARIE
Last Name:SANTIAGO
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 1:6500 BOWDEN RD STE 103
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8066
Mailing Address - Country:US
Mailing Address - Phone:904-634-0640
Mailing Address - Fax:904-634-0203
Practice Address - Street 1:10475 CENTURION PKWY N STE 220
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5004
Practice Address - Country:US
Practice Address - Phone:904-634-0640
Practice Address - Fax:904-634-0203
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9413788163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant