Healthcare Provider Details

I. General information

NPI: 1346712783
Provider Name (Legal Business Name): ELIZABETH DIZON SANTOS AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH SANTOS VALERA RN

II. Dates (important events)

Enumeration Date: 12/26/2018
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 HARMON LOOP RD STE 300
DEDEDO GU
96929-6544
US

IV. Provider business mailing address

425 CHALAN SAN ANTONIO
TAMUNING GU
96913-3602
US

V. Phone/Fax

Practice location:
  • Phone: 671-647-5355
  • Fax: 671-649-0404
Mailing address:
  • Phone: 671-688-2623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP0196
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: