Provider Demographics
NPI:1942752001
Name:SANTIAGO, EVELYN IVETTE (DIETITIAN)
Entity Type:Individual
Prefix:MISS
First Name:EVELYN
Middle Name:IVETTE
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:M11 CALLE ARECIBO
Mailing Address - Street 2:VILLA CARMEN
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:787-595-3224
Mailing Address - Fax:
Practice Address - Street 1:A26 CALLE FLAMBOYAN
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-6154
Practice Address - Country:US
Practice Address - Phone:787-595-3224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1892133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR$$$$$$$$$Medicare PIN