Provider Demographics
NPI:1922735430
Name:DISTASI SANTOS, DANIELLE NICOLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:NICOLE
Last Name:DISTASI 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 1:14 FARMSTEAD RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1506
Mailing Address - Country:US
Mailing Address - Phone:631-456-7977
Mailing Address - Fax:
Practice Address - Street 1:14 FARMSTEAD RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-1506
Practice Address - Country:US
Practice Address - Phone:631-456-7977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2197709174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty