Provider Demographics
NPI:1265273783
Name:ALSTON, ANTOINETTE EILEEN
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:EILEEN
Last Name:ALSTON
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 1:1202 ANNAPOLIS RD STE E
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1398
Mailing Address - Country:US
Mailing Address - Phone:410-417-7711
Mailing Address - Fax:
Practice Address - Street 1:1202 ANNAPOLIS RD STE E
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1398
Practice Address - Country:US
Practice Address - Phone:410-417-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRO1988225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist