Basic Information
| Provider Information | |||||||||
| NPI: | 1275925877 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTOS | ||||||||
| FirstName: | ROANNIE DIVINE | ||||||||
| MiddleName: | PAPA | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GUSTAVE L. LEVY PLACE | ||||||||
| Address2: | BOX 1030 (CATH LAB) | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122416500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4401 FRANCIS LEWIS BLVD STE L3A | ||||||||
| Address2: | |||||||||
| City: | BAYSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113613028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184233355 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2015 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F339421-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.