Provider Demographics
NPI:1659535466
Name:SANTIAGO, NIKKI RYAN
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:RYAN
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:RYAN
Other - Last Name:MERREL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2273 E GALA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7289
Mailing Address - Country:US
Mailing Address - Phone:208-898-9999
Mailing Address - Fax:208-898-8992
Practice Address - Street 1:2273 E GALA ST STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7289
Practice Address - Country:US
Practice Address - Phone:208-898-9999
Practice Address - Fax:208-898-8992
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 146M00000X, 171000000X
TMS246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
165935466OtherNPI