Provider Demographics
NPI:1407878929
Name:FONTENOT, LESLIE GAUTHIER (RD,LDN,CDE, MS)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:GAUTHIER
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:RD,LDN,CDE, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:4704 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6908
Practice Address - Country:US
Practice Address - Phone:337-371-3101
Practice Address - Fax:337-371-3157
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA713133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H812Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER