Provider Demographics
NPI:1790115012
Name:FONTEYNE, AMBER (NP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:FONTEYNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:LYN
Other - Last Name:BROTHERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:340 MAIN ST # 140A
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2524
Mailing Address - Country:US
Mailing Address - Phone:310-310-6380
Mailing Address - Fax:
Practice Address - Street 1:340 MAIN ST # 140A
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2524
Practice Address - Country:US
Practice Address - Phone:310-310-6380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19268363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health