Provider Demographics
NPI:1366685125
Name:ANTONUCCIO, JOAN MARIE
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:MARIE
Last Name:ANTONUCCIO
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 1:10200 TURKEY LAKE RD
Mailing Address - Street 2:UNTI 134
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8017
Mailing Address - Country:US
Mailing Address - Phone:407-968-7062
Mailing Address - Fax:
Practice Address - Street 1:10200 TURKEY LAKE RD
Practice Address - Street 2:UNIT 134
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8017
Practice Address - Country:US
Practice Address - Phone:407-968-7062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687809179OtherPROVIDER NUMBER