Healthcare Provider Details

I. General information

NPI: 1205654621
Provider Name (Legal Business Name): TANYA FONTENOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GENERAL MOUTON AVE
LAFAYETTE LA
70501-7826
US

IV. Provider business mailing address

120 N LIBERTY ST
OPELOUSAS LA
70570-5232
US

V. Phone/Fax

Practice location:
  • Phone: 337-298-9688
  • Fax: 337-363-5079
Mailing address:
  • Phone: 337-849-1095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN130284
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: