Provider Demographics
NPI:1730482423
Name:DANIELS, ANTILA DELOA (LPN)
Entity Type:Individual
Prefix:MS
First Name:ANTILA
Middle Name:DELOA
Last Name:DANIELS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2052 STEWART DR NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-2341
Mailing Address - Country:US
Mailing Address - Phone:330-974-8773
Mailing Address - Fax:330-989-2906
Practice Address - Street 1:2052 STEWART DR NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-2341
Practice Address - Country:US
Practice Address - Phone:330-974-8773
Practice Address - Fax:330-989-2906
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-17
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH131675164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3105857Medicaid