Basic Information
| Provider Information | |||||||||
| NPI: | 1861783417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONTENOT | ||||||||
| FirstName: | SENIA | ||||||||
| MiddleName: | TIMOTHY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ANP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 DOCTOR MICHAEL DEBAKEY DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706015724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373128258 | ||||||||
| FaxNumber: | 3373126711 | ||||||||
| Practice Location | |||||||||
| Address1: | 1747 IMPERIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706055362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377217236 | ||||||||
| FaxNumber: | 3377217237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2011 | ||||||||
| LastUpdateDate: | 03/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WX0800X | RN117238 | LA | N | Nursing Service Providers | Registered Nurse | Orthopedic | 363LA2200X | AP06594 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 2171381 | 05 | LA | MEDICAID |