Provider Demographics
NPI:1518431857
Name:FONTEM, ATEM
Entity Type:Individual
Prefix:
First Name:ATEM
Middle Name:
Last Name:FONTEM
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 1:4949 W DAVIS ST APT 9208
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-5336
Mailing Address - Country:US
Mailing Address - Phone:936-494-9884
Mailing Address - Fax:
Practice Address - Street 1:2400 AVENUE I
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-5830
Practice Address - Country:US
Practice Address - Phone:936-437-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034381801835P0018X
TX647041835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist