Healthcare Provider Details

I. General information

NPI: 1366685125
Provider Name (Legal Business Name): JOAN MARIE ANTONUCCIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 TURKEY LAKE RD UNIT 134
ORLANDO FL
32819-8017
US

IV. Provider business mailing address

10200 TURKEY LAKE RD UNTI 134
ORLANDO FL
32819-8017
US

V. Phone/Fax

Practice location:
  • Phone: 407-968-7062
  • Fax:
Mailing address:
  • Phone: 407-968-7062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: