Provider Demographics
NPI:1497303028
Name:DE SANTIAGO, STEPHANIE DIANNE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANNE
Last Name:DE 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 1:10515 W SANTA FE DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3020
Mailing Address - Country:US
Mailing Address - Phone:623-832-6530
Mailing Address - Fax:
Practice Address - Street 1:10515 W SANTA FE DR
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3020
Practice Address - Country:US
Practice Address - Phone:480-209-5629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ226871363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology