Provider Demographics
NPI:1982777264
Name:FONTENOT, MELISSA C (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:C
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3334 CAPITAL MEDICAL BLVD. #400
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4470
Mailing Address - Country:US
Mailing Address - Phone:850-877-8174
Mailing Address - Fax:844-261-6839
Practice Address - Street 1:3334 CAPITAL MEDICAL BLVD
Practice Address - Street 2:400
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8405
Practice Address - Country:US
Practice Address - Phone:850-877-8174
Practice Address - Fax:844-261-6839
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024969200Medicaid