=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659410991
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRY JOAN SANTIAGO NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 03/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4244 RIVERWALK PKWY SUITE 170
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-8509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-736-7432
-----------------------------------------------------
Fax | 951-736-7751
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2285 CORPORATE CIR STE 200
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89074-7759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-360-2763
-----------------------------------------------------
Fax | 949-783-2880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | NP14831
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------