Provider Demographics
NPI:1386229839
Name:FONTENOT, ELISSA GLORIA (NP)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:GLORIA
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PRINCETON CT
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-2953
Mailing Address - Country:US
Mailing Address - Phone:678-793-3123
Mailing Address - Fax:
Practice Address - Street 1:2801 DEKALB MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4996
Practice Address - Country:US
Practice Address - Phone:404-501-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN241909163WG0000X
GANCO-000003363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice