Healthcare Provider Details

I. General information

NPI: 1619155009
Provider Name (Legal Business Name): RAE ANN ANTONUCCI P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 NESBIT ST STE 112
PUNTA GORDA FL
33950-3653
US

IV. Provider business mailing address

122 NESBIT ST STE 112
PUNTA GORDA FL
33950-3653
US

V. Phone/Fax

Practice location:
  • Phone: 941-347-7707
  • Fax:
Mailing address:
  • Phone: 941-347-7707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9105373
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: