Provider Demographics
NPI:1710262498
Name:ANTONICH, MELANIE JOAN (ARNP)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:JOAN
Last Name:ANTONICH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 STATE AVE
Mailing Address - Street 2:SUITE I; PMB 1007
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-3672
Mailing Address - Country:US
Mailing Address - Phone:360-201-9541
Mailing Address - Fax:
Practice Address - Street 1:555 ANDOVER PARK W STE 200
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-3379
Practice Address - Country:US
Practice Address - Phone:888-803-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ256983363LF0000X
WAAP60262504367A00000X
WAAP60188632363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8931251Medicare UPIN