Provider Demographics
NPI:1265278840
Name:CUNDIFF, ANTOINETTE (CEO)
Entity type:Individual
Prefix:MRS
First Name:ANTOINETTE
Middle Name:
Last Name:CUNDIFF
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:MRS
Other - First Name:ANTOINETTE
Other - Middle Name:
Other - Last Name:PASSMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1841
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9641
Mailing Address - Country:US
Mailing Address - Phone:219-707-7100
Mailing Address - Fax:
Practice Address - Street 1:259 INDIANA AVE STE A9
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5573
Practice Address - Country:US
Practice Address - Phone:219-707-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN300082477374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide