Provider Demographics
NPI:1609462845
Name:ANTONIO, FIDES D (NP)
Entity Type:Individual
Prefix:
First Name:FIDES
Middle Name:D
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:NP
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Other - Last Name:
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Mailing Address - Street 1:901 MCCLINTOCK DR STE 202
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0872
Mailing Address - Country:US
Mailing Address - Phone:630-655-6748
Mailing Address - Fax:630-734-4715
Practice Address - Street 1:130 LA CASA VIA STE 108
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3036
Practice Address - Country:US
Practice Address - Phone:877-448-3627
Practice Address - Fax:866-507-1164
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95015546363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner