Provider Demographics
NPI:1629750898
Name:ANTONIO, MARITEL TINAZA
Entity Type:Individual
Prefix:
First Name:MARITEL
Middle Name:TINAZA
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 1:94-1190 LUMIKULA ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3943
Mailing Address - Country:US
Mailing Address - Phone:808-782-1381
Mailing Address - Fax:808-888-7808
Practice Address - Street 1:94-1190 LUMIKULA ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3943
Practice Address - Country:US
Practice Address - Phone:808-782-1381
Practice Address - Fax:808-888-7808
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home