Provider Demographics
NPI:1942829411
Name:SANTIAGO, KRISTAL M (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:M
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 ELDER LN
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-6020
Mailing Address - Country:US
Mailing Address - Phone:631-764-8485
Mailing Address - Fax:
Practice Address - Street 1:100 NICOLLS RD., HSC T12 RM 080
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-1535
Practice Address - Country:US
Practice Address - Phone:631-444-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346175363LF0000X
NY673328163WN0800X
NYF346175-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience