Provider Demographics
NPI:1922484757
Name:GUEDON, LACY FONTENOT (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:LACY
Middle Name:FONTENOT
Last Name:GUEDON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1300
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-3344
Mailing Address - Country:US
Mailing Address - Phone:318-435-6377
Mailing Address - Fax:318-435-6378
Practice Address - Street 1:2104 LOOP RD STE C
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-3341
Practice Address - Country:US
Practice Address - Phone:318-435-6377
Practice Address - Fax:318-435-6378
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08776364SP0810X
LAAP08776363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Family
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5YJC5OtherMEDICARE
13848326OtherCAQH
LAP02474675OtherRR MEDICARE
LA2421751Medicaid