Basic Information
| Provider Information | |||||||||
| NPI: | 1407390693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONTENEAUX | ||||||||
| FirstName: | NINA | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5009 UNIVERSITY AVE | ||||||||
| Address2: | STE C | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794134432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067121096 | ||||||||
| FaxNumber: | 8067712093 | ||||||||
| Practice Location | |||||||||
| Address1: | 16620 N US HIGHWAY 281 STE 300 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782322679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103091405 | ||||||||
| FaxNumber: | 2106884596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2016 | ||||||||
| LastUpdateDate: | 05/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP131805 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 47-5300786 | 01 | TX | TAX ID | OTHER |