Provider Demographics
NPI:1255491163
Name:ANTONIO, FAIRIN I (LVN II)
Entity Type:Individual
Prefix:MS
First Name:FAIRIN
Middle Name:I
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:LVN II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5029 WINTUN WAY
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-9690
Mailing Address - Country:US
Mailing Address - Phone:707-277-7667
Mailing Address - Fax:
Practice Address - Street 1:15145 A LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422
Practice Address - Country:US
Practice Address - Phone:707-994-7090
Practice Address - Fax:707-994-7096
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN169534164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse