Provider Demographics
NPI:1831710714
Name:SANTIAGO, ANNETTE (HOMEMAKER)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:HOMEMAKER
Other - Prefix:MS
Other - First Name:ANNETTE
Other - Middle Name:
Other - Last Name:SANTIAGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:HOMEMAKER
Mailing Address - Street 1:2019 SPRINGWOOD RD
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-7301
Mailing Address - Country:US
Mailing Address - Phone:228-219-4537
Mailing Address - Fax:
Practice Address - Street 1:2019 SPRINGWOOD RD
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-7301
Practice Address - Country:US
Practice Address - Phone:228-219-4537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS158093872982908376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS158093872982908Medicaid