Provider Demographics
NPI:1598052052
Name:FONTENOT, TED ETELL (ANP)
Entity Type:Individual
Prefix:MR
First Name:TED
Middle Name:ETELL
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:MR
Other - First Name:TED
Other - Middle Name:ETELL
Other - Last Name:FONTENOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:PO BOX 122152 DEPT 2152
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-0001
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:1717 OAK PARK BLVD FL 2
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8990
Practice Address - Country:US
Practice Address - Phone:337-494-3278
Practice Address - Fax:337-494-3240
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06448363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2159445Medicaid
LAAP06448OtherSTATE LICENSE