Provider Demographics
NPI:1306204052
Name:ANTOINE, DETRA
Entity Type:Individual
Prefix:
First Name:DETRA
Middle Name:
Last Name:ANTOINE
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 1:1201 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44306-2153
Mailing Address - Country:US
Mailing Address - Phone:330-203-4283
Mailing Address - Fax:
Practice Address - Street 1:1201 7TH AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44306-2153
Practice Address - Country:US
Practice Address - Phone:330-203-4283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4017895209153747P1801X, 376J00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker