Basic Information
| Provider Information | |||||||||
| NPI: | 1710262498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTONICH | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | JOAN | ||||||||
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| Credential: | A.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663662983 | ||||||||
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| Practice Location | |||||||||
| Address1: | 916 PACIFIC AVE 2ND FLOOR | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253036500 | ||||||||
| FaxNumber: | 4253036550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2011 | ||||||||
| LastUpdateDate: | 02/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | AP60188632 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 367A00000X | AP60262504 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.