Provider Demographics
NPI:1790115251
Name:MONTALVO, ANTONETTE (CRNP - PC)
Entity Type:Individual
Prefix:MRS
First Name:ANTONETTE
Middle Name:
Last Name:MONTALVO
Suffix:
Gender:F
Credentials:CRNP - PC
Other - Prefix:MS
Other - First Name:ANTONETTE
Other - Middle Name:
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP-PC
Mailing Address - Street 1:4417 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-2319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4417 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-2319
Practice Address - Country:US
Practice Address - Phone:215-302-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013412363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1029044300001Medicaid