Provider Demographics
NPI:1811667660
Name:ANTONIO, ANDERAE RACHELLE
Entity type:Individual
Prefix:
First Name:ANDERAE
Middle Name:RACHELLE
Last Name:ANTONIO
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 1:10316 E 120TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-4850
Mailing Address - Country:US
Mailing Address - Phone:512-229-6948
Mailing Address - Fax:
Practice Address - Street 1:2323 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-3301
Practice Address - Country:US
Practice Address - Phone:918-293-2140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator