Provider Demographics
NPI:1740449008
Name:OLUKUNLE, ANTIONETTE L
Entity type:Individual
Prefix:MRS
First Name:ANTIONETTE
Middle Name:L
Last Name:OLUKUNLE
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 1:7924 DIAMOND LEAF DR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-3454
Mailing Address - Country:US
Mailing Address - Phone:904-771-9875
Mailing Address - Fax:
Practice Address - Street 1:7924 DIAMOND LEAF DR S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-3454
Practice Address - Country:US
Practice Address - Phone:904-771-9875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686502096Medicaid
FL686502098Medicaid