Provider Demographics
NPI:1558066464
Name:SANTISTEVAN, ANGELA RAE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:RAE
Last Name:SANTISTEVAN
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 1:1800 E. 15TH ST.
Mailing Address - Street 2:#536
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609
Mailing Address - Country:US
Mailing Address - Phone:813-469-9540
Mailing Address - Fax:
Practice Address - Street 1:1800 E. 15TH ST.
Practice Address - Street 2:#536
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-8260
Practice Address - Country:US
Practice Address - Phone:813-469-9540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator