=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730398595
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE MICHELLE ANTONIO M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1690 BARTON RD STE 104
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92373-4230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-335-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 35380
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89133-5380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-579-3203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | A103315
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------