Provider Demographics
NPI:1053472449
Name:FONTENELLE-GILMER, MICHELLE A (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:FONTENELLE-GILMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 W CHARLESTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3014 W CHARLESTON BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-0083
Practice Address - Country:US
Practice Address - Phone:702-671-6475
Practice Address - Fax:702-671-6440
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010774692084P0800X
NV151372084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4377332Medicaid
MI0E86008038Medicare ID - Type UnspecifiedMEDICARE BILLING ID