Provider Demographics
NPI:1114036035
Name:ANTONOW, DEANNA
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:ANTONOW
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:RD2 BOX335
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:PA
Mailing Address - Zip Code:18837
Mailing Address - Country:US
Mailing Address - Phone:570-247-2749
Mailing Address - Fax:
Practice Address - Street 1:1537 ELMIRA ST
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-9254
Practice Address - Country:US
Practice Address - Phone:570-888-6803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education