Provider Demographics
NPI:1477992931
Name:CONVERSE-FONTENOT, SHIRLEY MAY
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:MAY
Last Name:CONVERSE-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 1:6673 E UPLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70812-1067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6673 E UPLAND AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70812-1067
Practice Address - Country:US
Practice Address - Phone:225-355-7156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN089146163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse