Provider Demographics
NPI:1376918912
Name:ANTONOVICH, STORMY (CDM)
Entity Type:Individual
Prefix:
First Name:STORMY
Middle Name:
Last Name:ANTONOVICH
Suffix:
Gender:F
Credentials:CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 BETULA DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-4141
Mailing Address - Country:US
Mailing Address - Phone:907-244-6402
Mailing Address - Fax:
Practice Address - Street 1:10100 BETULA DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-4141
Practice Address - Country:US
Practice Address - Phone:907-244-6402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK104743176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK104743OtherCERTIFIED DIRECT-ENTRY MIDWIFE