Basic Information
| Provider Information | |||||||||
| NPI: | 1881769982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONTENOT | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 ALLENS AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029055010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017802511 | ||||||||
| FaxNumber: | 4017802565 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018612403 | ||||||||
| FaxNumber: | 4015211145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN 04419 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | APRN02401 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1461504 | 05 | LA | MEDICAID |