Provider Demographics
NPI:1841759255
Name:ANTIGUA, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:ANTIGUA
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 1:2460 OLD MOULTRIE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4198
Mailing Address - Country:US
Mailing Address - Phone:904-293-0299
Mailing Address - Fax:904-797-7417
Practice Address - Street 1:2460 OLD MOULTRIE RD STE 5
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4198
Practice Address - Country:US
Practice Address - Phone:904-797-5740
Practice Address - Fax:904-797-5749
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000775363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OtherALL APPLICATIONS ARE PENDING