Provider Demographics
NPI:1447495189
Name:MCALLISTER-BLYDEN, ANTOINETTE VERONICA, FENOLA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:VERONICA, FENOLA
Last Name:MCALLISTER-BLYDEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
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Mailing Address - Street 1:LANDSTUHL REGIONAL MEDICAL CENTER UNIT 33100
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-3310
Mailing Address - Country:US
Mailing Address - Phone:314-590-9191
Mailing Address - Fax:
Practice Address - Street 1:LANDSTUHL REGIONAL MEDICAL CENTER UNIT 33100
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180
Practice Address - Country:US
Practice Address - Phone:314-590-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY018238-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04527928Medicaid