Healthcare Provider Details

I. General information

NPI: 1952716342
Provider Name (Legal Business Name): KASEY S FONTENOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LONGWOOD DR
THIBODAUX LA
70301-8027
US

IV. Provider business mailing address

101 LONGWOOD DR
THIBODAUX LA
70301-8027
US

V. Phone/Fax

Practice location:
  • Phone: 985-778-3148
  • Fax: 800-786-0683
Mailing address:
  • Phone: 985-778-3148
  • Fax: 800-786-0683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number1642
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: