Provider Demographics
NPI:1184382756
Name:ANTONIO, MYRTLE VIRGINIA
Entity type:Individual
Prefix:
First Name:MYRTLE
Middle Name:VIRGINIA
Last Name:ANTONIO
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 1:6413 S 12TH ST APT 1518
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-1985
Mailing Address - Country:US
Mailing Address - Phone:253-258-2352
Mailing Address - Fax:
Practice Address - Street 1:6413 S 12TH ST APT 1518
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-1985
Practice Address - Country:US
Practice Address - Phone:253-258-2352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty