Basic Information
| Provider Information | |||||||||
| NPI: | 1649770447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTIAGO | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 110429 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800420429 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 13535 NEMOURS PKWY | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328277402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075674000 | ||||||||
| FaxNumber: | 4075675924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2018 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9313661 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | C-APN.0002754-C-NP | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 208M00000X | ARNP9313661 | FL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 024405100 | 05 | FL | MEDICAID |