Provider Demographics
NPI:1518287127
Name:ANTONOVA, MICHELE G (RN)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:G
Last Name:ANTONOVA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 QUARRYSTONE LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1478
Mailing Address - Country:US
Mailing Address - Phone:631-365-1462
Mailing Address - Fax:
Practice Address - Street 1:2308 QUARRYSTONE LN
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-1478
Practice Address - Country:US
Practice Address - Phone:631-365-1462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY626949-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY626949-1Medicaid