Provider Demographics
NPI:1023448016
Name:DISTAN, ANTONETTE ELLESMERE
Entity type:Individual
Prefix:
First Name:ANTONETTE
Middle Name:ELLESMERE
Last Name:DISTAN
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 1:1601 ARNICA LN
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4442
Mailing Address - Country:US
Mailing Address - Phone:818-601-9714
Mailing Address - Fax:
Practice Address - Street 1:1601 ARNICA LN
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4442
Practice Address - Country:US
Practice Address - Phone:818-601-9714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16439225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist