Healthcare Provider Details

I. General information

NPI: 1639588551
Provider Name (Legal Business Name): ADZUA ANTENOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 E PARK AVE
NILES OH
44446-2352
US

IV. Provider business mailing address

3640 BURKEY RD
YOUNGSTOWN OH
44515-3335
US

V. Phone/Fax

Practice location:
  • Phone: 330-544-8005
  • Fax: 330-544-9379
Mailing address:
  • Phone: 718-807-7190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number534390
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: