=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396497475
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINCENT L. DI ANTONIO APN, PMHNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2022
-----------------------------------------------------
Last Update Date | 07/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 714 E MAIN ST STE 1A
-----------------------------------------------------
City | MOORESTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08057-3068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-391-0032
-----------------------------------------------------
Fax | 856-249-9651
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 985
-----------------------------------------------------
City | BENSALEM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19020-0985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-650-7855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ01413800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------