Provider Demographics
NPI:1235669425
Name:COLON, ANTOINETTA
Entity Type:Individual
Prefix:
First Name:ANTOINETTA
Middle Name:
Last Name:COLON
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 1:58 1ST AVENUE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3837
Mailing Address - Country:US
Mailing Address - Phone:516-480-0507
Mailing Address - Fax:
Practice Address - Street 1:1480 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-5412
Practice Address - Country:US
Practice Address - Phone:516-480-0507
Practice Address - Fax:631-849-5824
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist