Provider Demographics
NPI:1114076080
Name:FONTANILLA, ANGELITA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELITA
Middle Name:
Last Name:FONTANILLA
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 1:200 E FAIRMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1644
Mailing Address - Country:US
Mailing Address - Phone:815-432-5841
Mailing Address - Fax:
Practice Address - Street 1:200 LAIRD LN
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-7568
Practice Address - Country:US
Practice Address - Phone:815-432-5411
Practice Address - Fax:815-432-3955
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010379922080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine