Provider Demographics
NPI:1346744042
Name:FONTENOT, MARY NECOLOA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NECOLOA
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 1:1324 ROSETTA ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-1932
Mailing Address - Country:US
Mailing Address - Phone:337-912-8617
Mailing Address - Fax:
Practice Address - Street 1:1324 ROSETTA ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-1932
Practice Address - Country:US
Practice Address - Phone:337-912-8617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008907424171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA882717925Medicaid