Provider Demographics
NPI:1811087232
Name:ANTONIO, ANNA MARIE (FNP)
Entity type:Individual
Prefix:MISS
First Name:ANNA MARIE
Middle Name:
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 COURAGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6717
Mailing Address - Country:US
Mailing Address - Phone:707-784-2010
Mailing Address - Fax:
Practice Address - Street 1:2101 COURAGE DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6717
Practice Address - Country:US
Practice Address - Phone:707-784-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 15006363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP 0150060Medicaid
CANP 0150060Medicaid
CAQ74769Medicare UPIN