Provider Demographics
NPI:1669005310
Name:ANTONY, TIA ANNE
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:ANNE
Last Name:ANTONY
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 1:878 SE 25TH ST
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-3210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:878 SE 25TH ST
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34974-3210
Practice Address - Country:US
Practice Address - Phone:772-979-0415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9343406163W00000X
FL11024212367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA535801836650Medicaid