Basic Information
| Provider Information | |||||||||
| NPI: | 1003050600 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONETTI | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPTA13089 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANTONETTI | ||||||||
| OtherFirstName: | MARIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPTA13089 | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11242 SCENIC VISTA DR | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347118669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522475737 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 394 N SUNCOAST BLVD STE 40 | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL RIVER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344295466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527956225 | ||||||||
| FaxNumber: | 3527956065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2009 | ||||||||
| LastUpdateDate: | 11/15/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA13089 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 106898 | 01 | FL | MEDICARE ID | OTHER |