Provider Demographics
NPI:1871855999
Name:ANTONIK, TIFFANY LYNN (MA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:ANTONIK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 LITTLE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-4550
Mailing Address - Country:US
Mailing Address - Phone:631-747-2205
Mailing Address - Fax:
Practice Address - Street 1:25 LITTLE PLAINS RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4550
Practice Address - Country:US
Practice Address - Phone:631-747-2205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1106296174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1106296OtherSPECIAL EDUCATION TEACHER