Provider Demographics
NPI:1245612555
Name:SMITH, ANTOINETTE
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:SMITH
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 1:34090 PINEWOODS CIR APT 206
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-8215
Mailing Address - Country:US
Mailing Address - Phone:248-808-2495
Mailing Address - Fax:
Practice Address - Street 1:34090 PINEWOODS CIR APT 206
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-8215
Practice Address - Country:US
Practice Address - Phone:248-808-2495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703115181164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse