Basic Information
| Provider Information | |||||||||
| NPI: | 1427473230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONTENOT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ALDEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | ALDEN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1103 KALISTE SALOOM RD. | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379885646 | ||||||||
| FaxNumber: | 5177877365 | ||||||||
| Practice Location | |||||||||
| Address1: | 1103 KALISTE SALOOM RD. | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379885646 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2014 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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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 | 367500000X | 849661 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.