Provider Demographics
NPI:1053885897
Name:SANTIAGO FIDALGO, KIARA MELISSA
Entity type:Individual
Prefix:
First Name:KIARA
Middle Name:MELISSA
Last Name:SANTIAGO FIDALGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 CAUTIVA ALMACIGOS
Mailing Address - Street 2:HACIENDA SAN JOSE
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00727
Mailing Address - Country:US
Mailing Address - Phone:787-222-9926
Mailing Address - Fax:
Practice Address - Street 1:CARR 31 KM 24.0
Practice Address - Street 2:
Practice Address - City:JUNCOS
Practice Address - State:PR
Practice Address - Zip Code:00777
Practice Address - Country:US
Practice Address - Phone:787-713-1425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR006634183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5031801Medicaid