Provider Demographics
NPI:1033687470
Name:ANTONUCCI, LIANA JON
Entity Type:Individual
Prefix:
First Name:LIANA
Middle Name:JON
Last Name:ANTONUCCI
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 1:21408 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2117
Mailing Address - Country:US
Mailing Address - Phone:845-558-8814
Mailing Address - Fax:
Practice Address - Street 1:21408 40TH AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2117
Practice Address - Country:US
Practice Address - Phone:845-558-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-03
Last Update Date:2018-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1208684181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist