Provider Demographics
NPI:1710385034
Name:SILVA SANTISTEBAN, TALIA MAE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:TALIA
Middle Name:MAE
Last Name:SILVA SANTISTEBAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:TALIA
Other - Middle Name:MAE
Other - Last Name:BUNKERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:125 NW 20TH PL
Mailing Address - Street 2:APT 607
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1042
Mailing Address - Country:US
Mailing Address - Phone:541-805-9588
Mailing Address - Fax:
Practice Address - Street 1:118 N KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2435
Practice Address - Country:US
Practice Address - Phone:503-288-4454
Practice Address - Fax:503-288-1783
Is Sole Proprietor?:No
Enumeration Date:2014-12-18
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC170128171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist