Provider Demographics
NPI:1649422064
Name:FONTANA, ELLEN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:
Last Name:FONTANA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 GUADALUPE ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-4296
Mailing Address - Country:US
Mailing Address - Phone:512-419-2770
Mailing Address - Fax:
Practice Address - Street 1:4110 GUADALUPE ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-4296
Practice Address - Country:US
Practice Address - Phone:512-419-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX686654363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health