Provider Demographics
NPI:1841912623
Name:ANTONUCCI, MICHELLE MARIE (OD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:ANTONUCCI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 8TH AVE N UNIT 904
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-5325
Mailing Address - Country:US
Mailing Address - Phone:661-433-1665
Mailing Address - Fax:
Practice Address - Street 1:740 DENNY WAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-5101
Practice Address - Country:US
Practice Address - Phone:206-588-1241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35196152W00000X
WAOD61480506152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist