Basic Information
| Provider Information | |||||||||
| NPI: | 1700558020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTOINE | ||||||||
| FirstName: | EDLINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PMHNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ESTIMABLE | ||||||||
| OtherFirstName: | EDLINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 215 FRANKEL BLVD | ||||||||
| Address2: | |||||||||
| City: | MERRICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115664796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165285186 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17900 LINDEN BLVD | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114250001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185261000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2021 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | F403748-01 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.