Provider Demographics
NPI:1952716342
Name:FONTENOT, KASEY S
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:S
Last Name:FONTENOT
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 1:101 LONGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-8027
Mailing Address - Country:US
Mailing Address - Phone:985-778-3148
Mailing Address - Fax:800-786-0683
Practice Address - Street 1:101 LONGWOOD DR
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-8027
Practice Address - Country:US
Practice Address - Phone:985-778-3148
Practice Address - Fax:800-786-0683
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1642246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist