Provider Demographics
NPI:1134692841
Name:FONTENOT, RONNICA
Entity Type:Individual
Prefix:
First Name:RONNICA
Middle Name:
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CHINABERRY DR STE 902
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2455
Mailing Address - Country:US
Mailing Address - Phone:318-473-4328
Mailing Address - Fax:
Practice Address - Street 1:905 E 7TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:LA
Practice Address - Zip Code:71463-2788
Practice Address - Country:US
Practice Address - Phone:318-335-1048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203783184171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator