Provider Demographics
NPI:1225207335
Name:FONTENOT, CARLA (RN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:PROVIDER ENROLLMENT -- RT. 1022
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-5302
Mailing Address - Country:US
Mailing Address - Phone:409-747-0890
Mailing Address - Fax:409-747-1023
Practice Address - Street 1:2503 S MAIN ST
Practice Address - Street 2:STE B
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-5544
Practice Address - Country:US
Practice Address - Phone:281-499-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX670560163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse