Provider Demographics
NPI:1104344175
Name:FONTENOT, EVANGELINE MARIE (FNP-C)
Entity type:Individual
Prefix:
First Name:EVANGELINE
Middle Name:MARIE
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:EVANGELINE
Other - Middle Name:
Other - Last Name:KILCULLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-4278
Practice Address - Street 1:8369 FLORIDA BLVD STE 8
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-7862
Practice Address - Country:US
Practice Address - Phone:225-765-5500
Practice Address - Fax:225-667-1770
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09588363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAP09588OtherNURSE PRACTITIONER LIC NUMBER