Provider Demographics
NPI:1710773361
Name:DOUGLAS, ANTENISHA
Entity type:Individual
Prefix:
First Name:ANTENISHA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2889 E 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-4803
Mailing Address - Country:US
Mailing Address - Phone:216-310-3498
Mailing Address - Fax:
Practice Address - Street 1:1500 E 193RD ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44117-1373
Practice Address - Country:US
Practice Address - Phone:216-563-2598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide