Provider Demographics
NPI:1609063098
Name:ANTONIO, DIANA E
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:E
Last Name:ANTONIO
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 1:7425 RANCHO LOS GUILICOS RD
Mailing Address - Street 2:DEPT A
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-6519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7425 RANCHO LOS GUILICOS RD
Practice Address - Street 2:DEPT A
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-6519
Practice Address - Country:US
Practice Address - Phone:707-537-6387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN522800163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse