Provider Demographics
NPI:1659739860
Name:WASHINGTON, ANTWONE
Entity Type:Individual
Prefix:
First Name:ANTWONE
Middle Name:
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20267 OAKFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2148
Mailing Address - Country:US
Mailing Address - Phone:313-974-1749
Mailing Address - Fax:
Practice Address - Street 1:20267 OAKFIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2148
Practice Address - Country:US
Practice Address - Phone:313-974-1749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker