1104344175 NPI number — EVANGELINE MARIE FONTENOT FNP-C

Table of content: MISS INESHA VONIQUE BAKER DMD (NPI 1295388031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104344175 NPI number — EVANGELINE MARIE FONTENOT FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONTENOT
Provider First Name:
EVANGELINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KILCULLEN
Provider Other First Name:
EVANGELINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104344175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5959 S SHERWOOD FOREST BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-6038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-765-5727
Provider Business Mailing Address Fax Number:
225-765-4278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8369 FLORIDA BLVD STE 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENHAM SPRINGS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70726-7862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-765-5500
Provider Business Practice Location Address Fax Number:
225-667-1770
Provider Enumeration Date:
08/30/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP09588 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AP09588 . This is a "NURSE PRACTITIONER LIC NUMBER" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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