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General NPI Number Information
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NPI Number | 1679997027
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Entity Type | Individual
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Provider Name | JENNIFER ANTILL LMT
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Gender | Female
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Dates
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Enumeration Date | 02/05/2014
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Last Update Date | 01/20/2016
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Provider Practice Location Address
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Address Line | 32 PASEO DEL VALLE
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City | SANTA FE
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State | NM
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Zip | 87508-1402
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Country | US
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Telephone | 505-603-1629
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6402
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City | SANTA FE
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State | NM
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Zip | 87502-6402
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Country | US
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Telephone | 505-603-1629
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 7783
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License Number State | NM
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