Provider Demographics
NPI:1932686219
Name:FONTENOT, STACY NICOLE (MS, CF-SLP)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:NICOLE
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7013 SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-9056
Mailing Address - Country:US
Mailing Address - Phone:337-302-7505
Mailing Address - Fax:
Practice Address - Street 1:1905 TYBEE LN
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4172
Practice Address - Country:US
Practice Address - Phone:337-419-0086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7296235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist