Provider Demographics
NPI:1801267976
Name:MARIA, ANTOINETTE (NP)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:MARIA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3332
Mailing Address - Country:US
Mailing Address - Phone:607-733-5696
Mailing Address - Fax:
Practice Address - Street 1:1019 E WATER ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3332
Practice Address - Country:US
Practice Address - Phone:607-733-5696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY621471163WP0808X
NY1578240363LP0808X
NY403621363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04978007Medicaid