Provider Demographics
NPI:1629608047
Name:DE LOS SANTOS, SADELYN
Entity Type:Individual
Prefix:
First Name:SADELYN
Middle Name:
Last Name:DE LOS SANTOS
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 1:251 N 71ST TER
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-7364
Mailing Address - Country:US
Mailing Address - Phone:917-215-4270
Mailing Address - Fax:
Practice Address - Street 1:1200 N FEDERAL HWY STE 100
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-2844
Practice Address - Country:US
Practice Address - Phone:561-266-0190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112856363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant