Provider Demographics
NPI:1578079695
Name:FONTANGE, CARLA (LPN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:FONTANGE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 BROOKDALE GDNS APT D
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-6396
Mailing Address - Country:US
Mailing Address - Phone:973-444-7299
Mailing Address - Fax:
Practice Address - Street 1:16937 144TH RD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-5929
Practice Address - Country:US
Practice Address - Phone:718-978-7221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP06944700164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse