1982143335 NPI number — SHANNAN CANTU SANTOLI CNM

Table of content: SHANNAN CANTU SANTOLI CNM (NPI 1982143335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982143335 NPI number — SHANNAN CANTU SANTOLI CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANTU SANTOLI
Provider First Name:
SHANNAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982143335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5050 SOUTH LAKE DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUDAHY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53110-6108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-997-5266
Provider Business Mailing Address Fax Number:
618-997-5285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 SOUTH LAKE DR.
Provider Second Line Business Practice Location Address:
#100510
Provider Business Practice Location Address City Name:
CUDAHY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53110-6108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-769-2239
Provider Business Practice Location Address Fax Number:
618-997-5285
Provider Enumeration Date:
02/17/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  209015629 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 176B00000X , with the licence number: 148990-32 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1982143335 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1000-947-56 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".