Provider Demographics
NPI:1326583618
Name:REDDRICK, ANTIONETTE
Entity Type:Individual
Prefix:
First Name:ANTIONETTE
Middle Name:
Last Name:REDDRICK
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 1:180 SIERRA COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5768
Mailing Address - Country:US
Mailing Address - Phone:530-273-9541
Mailing Address - Fax:
Practice Address - Street 1:180 SIERRA COLLEGE DR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5768
Practice Address - Country:US
Practice Address - Phone:530-273-9541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 170896164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse