Healthcare Provider Details

I. General information

NPI: 1386778967
Provider Name (Legal Business Name): ETHEL ANTONIO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31194 LA BAYA DR
WESTLAKE VILLAGE CA
91362-4022
US

IV. Provider business mailing address

31194 LA BAYA DR
WESTLAKE VILLAGE CA
91362-4022
US

V. Phone/Fax

Practice location:
  • Phone: 805-341-3416
  • Fax: 818-369-0197
Mailing address:
  • Phone: 805-341-3416
  • Fax: 818-369-0197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95007507
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95007507
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: