Provider Demographics
NPI:1285896902
Name:ANTOINE, MARIE M (RN)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:M
Last Name:ANTOINE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 SE BISBEE ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4918
Mailing Address - Country:US
Mailing Address - Phone:772-626-8026
Mailing Address - Fax:772-873-4670
Practice Address - Street 1:6455 NW FAVIAN CT
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-4405
Practice Address - Country:US
Practice Address - Phone:772-626-8026
Practice Address - Fax:772-873-4670
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN 2015392163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL685946196Medicaid