Provider Demographics
NPI:1265947451
Name:PATE, ANTONIANNETTE (FNP-C)
Entity type:Individual
Prefix:
First Name:ANTONIANNETTE
Middle Name:
Last Name:PATE
Suffix:
Gender:F
Credentials:FNP-C
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 193
Mailing Address - Street 2:
Mailing Address - City:BOODY
Mailing Address - State:IL
Mailing Address - Zip Code:62514-0193
Mailing Address - Country:US
Mailing Address - Phone:217-853-5661
Mailing Address - Fax:
Practice Address - Street 1:1750 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3803
Practice Address - Country:US
Practice Address - Phone:217-464-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-10
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016156363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily