Provider Demographics
NPI:1730732991
Name:TIAM, ANTONETTE
Entity type:Individual
Prefix:
First Name:ANTONETTE
Middle Name:
Last Name:TIAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 EDGEWORTH ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3235
Mailing Address - Country:US
Mailing Address - Phone:516-815-5321
Mailing Address - Fax:
Practice Address - Street 1:89 EDGEWORTH ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3235
Practice Address - Country:US
Practice Address - Phone:516-815-5321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY767586163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse