Provider Demographics
NPI:1225782840
Name:YOUNG, ANTOINETTE WISSEH
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:WISSEH
Last Name:YOUNG
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 1:1405 VETERANS HWY APT M7
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:PA
Mailing Address - Zip Code:19007-2337
Mailing Address - Country:US
Mailing Address - Phone:602-551-5448
Mailing Address - Fax:
Practice Address - Street 1:1405 VETERANS HWY APT M7
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:PA
Practice Address - Zip Code:19007-2337
Practice Address - Country:US
Practice Address - Phone:602-551-5448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA5216890372600000X
374U00000X, 376J00000X, 376K00000X, 385H00000X
PA376J00000X, 385H00000X
PA99536210374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care