Provider Demographics
NPI:1235129727
Name:ROY, DIANA FONTENOT (CRNA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:FONTENOT
Last Name:ROY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:FONTENOT
Other - Last Name:ROY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:104 MISSION HILLS
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518
Mailing Address - Country:US
Mailing Address - Phone:337-856-0747
Mailing Address - Fax:
Practice Address - Street 1:2390 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4205
Practice Address - Country:US
Practice Address - Phone:337-261-6272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA36487163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice