Provider Demographics
NPI:1306615729
Name:COATES, ANTIONETTE RUBY
Entity type:Individual
Prefix:
First Name:ANTIONETTE
Middle Name:RUBY
Last Name:COATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANTIONETTE
Other - Middle Name:RUBY
Other - Last Name:COATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9912 FILLMORE ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-3533
Mailing Address - Country:US
Mailing Address - Phone:612-296-1991
Mailing Address - Fax:
Practice Address - Street 1:9912 FILLMORE ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3533
Practice Address - Country:US
Practice Address - Phone:612-296-1991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNM103113024104172A00000X
MNM10311302104172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver