Provider Demographics
NPI:1376827816
Name:ANTILLA, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ANTILLA
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 1:2800 CLEVELAND AVE N
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1126
Mailing Address - Country:US
Mailing Address - Phone:651-642-1825
Mailing Address - Fax:
Practice Address - Street 1:2800 CLEVELAND AVE N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1126
Practice Address - Country:US
Practice Address - Phone:651-642-1825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 201682-7163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse