Provider Demographics
NPI:1831503960
Name:FONTNEAU, CHARLENE ERNESTINE
Entity type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:ERNESTINE
Last Name:FONTNEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 WALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWOGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225
Mailing Address - Country:US
Mailing Address - Phone:716-894-7777
Mailing Address - Fax:
Practice Address - Street 1:1680 WALDEN AVE
Practice Address - Street 2:AFTERCARE
Practice Address - City:CHEEKTOWOGA
Practice Address - State:NY
Practice Address - Zip Code:14225
Practice Address - Country:US
Practice Address - Phone:716-894-7777
Practice Address - Fax:716-894-0604
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271434-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY271434-1OtherLPN