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General NPI Number Information
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NPI Number | 1417754284
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Entity Type | Individual
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Provider Name | BRYAN JOEY FONSECA PMHNP
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Gender | Male
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Dates
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Enumeration Date | 02/27/2025
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Last Update Date | 02/27/2025
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Provider Practice Location Address
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Address Line | 805 BARROW ST STE 3
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City | HOUMA
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State | LA
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Zip | 70360-4722
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Country | US
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Telephone | 985-857-3615
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Fax |
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Provider Business Mailing Address
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Address Line | 129 LOBLOLLY PINE DR
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City | GRAY
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State | LA
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Zip | 70359-2303
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Country | US
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Telephone | 985-665-7404
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 210513
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License Number State | LA
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