Provider Demographics
NPI:1679103535
Name:DE SANTIAGO, BERENICE
Entity type:Individual
Prefix:
First Name:BERENICE
Middle Name:
Last Name:DE SANTIAGO
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:PO BOX 4898
Mailing Address - Street 2:
Mailing Address - City:SUNLAND PARK
Mailing Address - State:NM
Mailing Address - Zip Code:88063-4898
Mailing Address - Country:US
Mailing Address - Phone:915-300-3992
Mailing Address - Fax:
Practice Address - Street 1:5312 RIO BRAVO DR STE 10
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9210
Practice Address - Country:US
Practice Address - Phone:915-300-3992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-20
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker