1114254893 NPI number — MS. CARRIE AMELIA FONTENOT MHPP

Table of content: MS. CARRIE AMELIA FONTENOT MHPP (NPI 1114254893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114254893 NPI number — MS. CARRIE AMELIA FONTENOT MHPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONTENOT
Provider First Name:
CARRIE
Provider Middle Name:
AMELIA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MHPP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114254893
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5537 BLEAUX AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGDALE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72762-0737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-872-5580
Provider Business Mailing Address Fax Number:
479-872-5581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1008 PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARKADELPHIA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71923-4919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-230-8364
Provider Business Practice Location Address Fax Number:
870-230-8381
Provider Enumeration Date:
11/17/2009

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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