Healthcare Provider Details

I. General information

NPI: 1073421814
Provider Name (Legal Business Name): GWENETH FONTANILLA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6741 BURNS ST APT 105
FOREST HILLS NY
11375-3552
US

IV. Provider business mailing address

6741 BURNS ST APT 105
FOREST HILLS NY
11375-3552
US

V. Phone/Fax

Practice location:
  • Phone: 404-717-3062
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number409070
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: