Healthcare Provider Details

I. General information

NPI: 1568086841
Provider Name (Legal Business Name): ANDREA DESANTIAGO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7205 S GEORGE BLVD
SEBRING FL
33875-5847
US

IV. Provider business mailing address

3054 VERMILLION CT
ZOLFO SPRINGS FL
33890-9620
US

V. Phone/Fax

Practice location:
  • Phone: 863-382-7277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN9397850
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: