Healthcare Provider Details

I. General information

NPI: 1659535466
Provider Name (Legal Business Name): NIKKI RYAN SANTIAGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKKI RYAN MERREL

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2273 E GALA ST STE 100
MERIDIAN ID
83642-7289
US

IV. Provider business mailing address

2273 E GALA ST STE 100
MERIDIAN ID
83642-7289
US

V. Phone/Fax

Practice location:
  • Phone: 208-898-9999
  • Fax: 208-898-8992
Mailing address:
  • Phone: 208-898-9999
  • Fax: 208-898-8992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberTMS
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: