Basic Information
| Provider Information | |||||||||
| NPI: | 1366169476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTOS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE SOUSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 57 OSAGE ST | ||||||||
| Address2: | |||||||||
| City: | SELDEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117842729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319428458 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3141 MOULTON PKWY | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499169100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2022 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F349759 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.