Healthcare Provider Details

I. General information

NPI: 1588075089
Provider Name (Legal Business Name): NICOLE SANTIAGO RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5117 SW 122ND TERRACE
COOPER CITY FL
33330
US

IV. Provider business mailing address

5117 SW 122ND TERREACE
COOPER CITY FL
33330
US

V. Phone/Fax

Practice location:
  • Phone: 754-368-5616
  • Fax:
Mailing address:
  • Phone: 754-368-5616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279P3900X
TaxonomyNeonatal/Pediatric Registered Respiratory Therapist
License NumberRT9805
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: