Provider Demographics
NPI:1417601717
Name:SANTIAGO, RAQUEL S (SUPPLIER)
Entity Type:Individual
Prefix:MS
First Name:RAQUEL
Middle Name:S
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:SUPPLIER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 SIMPSON RIDGE CIR APT D
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4487
Mailing Address - Country:US
Mailing Address - Phone:140-743-2615
Mailing Address - Fax:
Practice Address - Street 1:2302 SIMPSON RIDGE CIR APT D
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4487
Practice Address - Country:US
Practice Address - Phone:140-743-2615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA