Provider Demographics
NPI:1366169476
Name:SANTOS, NICOLE MARIE SOUSA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE SOUSA
Last Name:SANTOS
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 1:57 OSAGE ST
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2729
Mailing Address - Country:US
Mailing Address - Phone:631-942-8458
Mailing Address - Fax:
Practice Address - Street 1:3141 MOULTON PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653
Practice Address - Country:US
Practice Address - Phone:949-916-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF349759363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily