Provider Demographics
NPI:1053781377
Name:ANTONIW, CAROLYN E (MSRDN)
Entity type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:E
Last Name:ANTONIW
Suffix:
Gender:F
Credentials:MSRDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 STEUBEN STREET
Mailing Address - Street 2:
Mailing Address - City:MONTOUR FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14865
Mailing Address - Country:US
Mailing Address - Phone:607-535-7121
Mailing Address - Fax:607-210-1936
Practice Address - Street 1:220 STEUBEN STREET
Practice Address - Street 2:
Practice Address - City:MONTOUR FALLS
Practice Address - State:NY
Practice Address - Zip Code:14865
Practice Address - Country:US
Practice Address - Phone:607-535-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006214-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered