Provider Demographics
NPI:1720500135
Name:SANTOS, NICOLETTE VICENTE
Entity Type:Individual
Prefix:MISS
First Name:NICOLETTE
Middle Name:VICENTE
Last Name: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 1:150 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-2513
Mailing Address - Country:US
Mailing Address - Phone:831-883-9920
Mailing Address - Fax:831-883-9942
Practice Address - Street 1:150 BEACH RD
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-2513
Practice Address - Country:US
Practice Address - Phone:831-883-9920
Practice Address - Fax:831-883-9942
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA150367183700000X
CA76540183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No183700000XPharmacy Service ProvidersPharmacy Technician