MEDICARE: MS. STACY NICOLE FONTENOT MS, CF-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	7296	LA

General Provider Information

NPI Number	:	1932686219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STACY NICOLE FONTENOT MS, CF-SLP

Provider Business Mailing Address
First Line	:	7013 SHADOW LN
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-9056
Country	:	US
Telephone Number	:	337-302-7505
Fax Number	:

Provider Business Practice Location Address
First Line	:	1905 TYBEE LN
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-4172
Country	:	US
Telephone Number	:	337-419-0086
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2018
Last Update Date	:	07/19/2018

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