MEDICARE: AMBER RENEE FONTENOT ATC CSFA OPA-C OTC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer
2	246ZC0007X	Surgical Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AT9356	OTHER	TX	LAT
2	100280128	OTHER		NBSTSA
3	20-9011	OTHER		NBCOTA

General Provider Information

NPI Number	:	1750822581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBER RENEE FONTENOT ATC CSFA OPA-C OTC

Provider Business Mailing Address
First Line	:	852 SUGARTREE DR
Second Line	:
City	:	CLEBURNE
State	:	TX
Zip	:	76031-5253
Country	:	US
Telephone Number	:	832-683-7666
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 HIGHWAY 287 S
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-5701
Country	:	US
Telephone Number	:	817-968-5806
Fax Number	:	915-703-7745

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2017
Last Update Date	:	06/06/2025

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