Provider Demographics
NPI:1972578110
Name:ANTONIOLI VANCE, LORRAINE C (CRNFA)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:C
Last Name:ANTONIOLI VANCE
Suffix:
Gender:F
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34864
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-4864
Mailing Address - Country:US
Mailing Address - Phone:602-744-4760
Mailing Address - Fax:602-445-4079
Practice Address - Street 1:1850 N CENTRAL AVE
Practice Address - Street 2:SUITE 1600
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4527
Practice Address - Country:US
Practice Address - Phone:602-262-8900
Practice Address - Fax:602-445-4079
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN063282363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0162540OtherBCBS OF AZ
AZ187387Medicaid