Healthcare Provider Details

I. General information

NPI: 1053472449
Provider Name (Legal Business Name): MICHELLE A FONTENELLE-GILMER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9440 W SAHARA AVE STE 237
LAS VEGAS NV
89117-8821
US

IV. Provider business mailing address

9701 ROYAL LAMB DR
LAS VEGAS NV
89145-8660
US

V. Phone/Fax

Practice location:
  • Phone: 702-765-4965
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301077469
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number15137
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: