Provider Demographics
NPI:1710505300
Name:ANTONELLI, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ANTONELLI
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 1:11200 SW 8TH ST
Mailing Address - Street 2:ACH3- 336
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33199-2516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11200 SW 8TH ST
Practice Address - Street 2:ACH3 - 336
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33199-4280
Practice Address - Country:US
Practice Address - Phone:401-871-2724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program