Provider Demographics
NPI:1497254932
Name:SANTIAGO, TENISHIA KIM (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:TENISHIA
Middle Name:KIM
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:TENISHIA
Other - Middle Name:KIM
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1631 MIDTOWN PL STE 104-110
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-1300
Mailing Address - Country:US
Mailing Address - Phone:336-355-2142
Mailing Address - Fax:336-933-8280
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2538
Practice Address - Country:US
Practice Address - Phone:910-449-2779
Practice Address - Fax:910-450-4452
Is Sole Proprietor?:No
Enumeration Date:2018-02-11
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN273857363LP0808X
VA0024176300363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003208756AMedicaid