Healthcare Provider Details

I. General information

NPI: 1154827392
Provider Name (Legal Business Name): ERIN KORYN FONTENOT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 UNION AVE
MEMPHIS TN
38104-3415
US

IV. Provider business mailing address

1265 UNION AVE
MEMPHIS TN
38104-3415
US

V. Phone/Fax

Practice location:
  • Phone: 901-516-8330
  • Fax: 901-516-8252
Mailing address:
  • Phone: 901-516-8330
  • Fax: 901-516-8252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR869363
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: