Provider Demographics
NPI:1881839397
Name:ANTONETTI, MARYELLEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARYELLEN
Middle Name:
Last Name:ANTONETTI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10940 HAYDN DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33498-6752
Mailing Address - Country:US
Mailing Address - Phone:561-212-0368
Mailing Address - Fax:
Practice Address - Street 1:10940 HAYDN DR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33498-6752
Practice Address - Country:US
Practice Address - Phone:561-212-0368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0003250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant