MEDICARE: KELLY ANN ANTONIAK FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	11045692	FL

General Provider Information

NPI Number	:	1699621029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ANN ANTONIAK FNP-BC

Provider Business Mailing Address
First Line	:	218 LOTUS DR
Second Line	:
City	:	SAFETY HARBOR
State	:	FL
Zip	:	34695-4718
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	218 LOTUS DR
Second Line	:
City	:	SAFETY HARBOR
State	:	FL
Zip	:	34695-4718
Country	:	US
Telephone Number	:	949-636-5604
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2026
Last Update Date	:	03/09/2026

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