Provider Demographics
NPI:1710430392
Name:LOMIBAO SANTIAGO, MARTINA
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:LOMIBAO SANTIAGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARTINA
Other - Middle Name:
Other - Last Name:LOMIBAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:880 W CENTRAL RD
Mailing Address - Street 2:SUITE 4500
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2355
Mailing Address - Country:US
Mailing Address - Phone:847-398-2777
Mailing Address - Fax:847-394-2777
Practice Address - Street 1:880 W CENTRAL RD
Practice Address - Street 2:SUITE 4500
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2355
Practice Address - Country:US
Practice Address - Phone:847-398-2777
Practice Address - Fax:847-394-2777
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041366794163W00000X
IL209014798363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209014798OtherSTATE LICENSE