Provider Demographics
NPI:1770889321
Name:SEVASTOS, NICOLE MARIE SANTIAGO (CRNA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE SANTIAGO
Last Name:SEVASTOS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5560 LANSBURY LN
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-3818
Mailing Address - Country:US
Mailing Address - Phone:330-559-4289
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-444-6547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-30
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12154367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered