Provider Demographics
NPI:1750158382
Name:SANTIAGO, KELLANEY CLAYTOR
Entity type:Individual
Prefix:
First Name:KELLANEY
Middle Name:CLAYTOR
Last Name:SANTIAGO
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 1:6921 WATERBROOK CT
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-3924
Mailing Address - Country:US
Mailing Address - Phone:813-525-5463
Mailing Address - Fax:
Practice Address - Street 1:6921 WATERBROOK CT
Practice Address - Street 2:
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-3924
Practice Address - Country:US
Practice Address - Phone:813-525-5463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11029809363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty