Provider Demographics
NPI:1437595493
Name:MASAQUEL-SANTIAGO, DIVINA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:DIVINA
Middle Name:
Last Name:MASAQUEL-SANTIAGO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8006 BRIAR OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-5172
Mailing Address - Country:US
Mailing Address - Phone:650-580-7253
Mailing Address - Fax:
Practice Address - Street 1:8006 BRIAR OAKS DR
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94582-5172
Practice Address - Country:US
Practice Address - Phone:650-580-3155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22518164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse