Provider Demographics
NPI:1376839308
Name:BURNS, ANTOINETTE J
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:J
Last Name:BURNS
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 1:2341 SW FRISCO TER
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:96 SW ALLAPATTAH RD
Practice Address - Street 2:
Practice Address - City:INDIANTOWN
Practice Address - State:FL
Practice Address - Zip Code:34956-4307
Practice Address - Country:US
Practice Address - Phone:772-597-9468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPT3959183700000X
FL420101071250616183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician