Provider Demographics
NPI:1568697563
Name:FONTENOT, CRYSTAL ARDOIN (NP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ARDOIN
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 1:2000 OPELOUSAS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-2641
Mailing Address - Country:US
Mailing Address - Phone:337-439-9983
Mailing Address - Fax:
Practice Address - Street 1:2000 OPELOUSAS ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-2641
Practice Address - Country:US
Practice Address - Phone:337-439-9983
Practice Address - Fax:337-439-9250
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN103946-AP05780363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health