Provider Demographics
NPI:1689724700
Name:ANTLE, DENISE ELAINE (ARNP, MSN, CCNS)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:ELAINE
Last Name:ANTLE
Suffix:
Gender:F
Credentials:ARNP, MSN, CCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-4330
Mailing Address - Country:US
Mailing Address - Phone:563-326-4499
Mailing Address - Fax:
Practice Address - Street 1:1236 E RUSHOLME ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2473
Practice Address - Country:US
Practice Address - Phone:563-421-3994
Practice Address - Fax:563-421-3999
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA055474364SC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA436543Medicaid
506291OtherIOWA HEALTH SOLUTION
IA16064OtherWELLMARK BCBS
IA436543Medicaid
IA16064OtherWELLMARK BCBS