Healthcare Provider Details

I. General information

NPI: 1700214988
Provider Name (Legal Business Name): EVELYN SANTIAGO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2013
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 OLD FIREHOUSE ROAD
WALLKILL NY
12589
US

IV. Provider business mailing address

2570 ROUTE 9W SUITE 10
CORNWALL NY
12518
US

V. Phone/Fax

Practice location:
  • Phone: 845-563-8000
  • Fax:
Mailing address:
  • Phone: 845-220-3100
  • Fax: 845-534-2940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number581312
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF338358
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: