Healthcare Provider Details

I. General information

NPI: 1942829411
Provider Name (Legal Business Name): KRISTAL M SANTIAGO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NICOLLS RD., HSC T12 RM 080
STONY BROOK NY
11794-1535
US

IV. Provider business mailing address

557 ELDER LN
RONKONKOMA NY
11779-6020
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-1116
  • Fax:
Mailing address:
  • Phone: 631-764-8485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF346175-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number346175
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163WN0800X
TaxonomyNeuroscience Registered Nurse
License Number673328
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: