Provider Demographics
NPI:1619583705
Name:SANTOS, MAYRA PITOMBO (AS)
Entity Type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:PITOMBO
Last Name:SANTOS
Suffix:
Gender:F
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 NW EMILIA WAY
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-3507
Mailing Address - Country:US
Mailing Address - Phone:203-727-7502
Mailing Address - Fax:
Practice Address - Street 1:332 NW EMILIA WAY
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-3507
Practice Address - Country:US
Practice Address - Phone:203-727-7502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17218227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered