Provider Demographics
NPI:1447398631
Name:FONTENOT UMFRID, HOLLY A (APRN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:A
Last Name:FONTENOT UMFRID
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 ROYER LOOP
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-0217
Mailing Address - Country:US
Mailing Address - Phone:337-831-5914
Mailing Address - Fax:
Practice Address - Street 1:109 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-5328
Practice Address - Country:US
Practice Address - Phone:337-217-0922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN097876 AP04679363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1315711Medicaid
LA1315711Medicaid
LAQ52875Medicare UPIN