Provider Demographics
NPI:1720736747
Name:SALLIS, ANTOINETTE CORIN
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:CORIN
Last Name:SALLIS
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 1:9817 W LISBON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-2406
Mailing Address - Country:US
Mailing Address - Phone:414-477-4576
Mailing Address - Fax:
Practice Address - Street 1:9817 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-2406
Practice Address - Country:US
Practice Address - Phone:414-477-4576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management