Provider Demographics
NPI:1427473230
Name:FONTENOT, MARY ALDEN (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALDEN
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ALDEN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1103 KALISTE SALOOM RD.
Mailing Address - Street 2:SUITE 304
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508
Mailing Address - Country:US
Mailing Address - Phone:337-988-5646
Mailing Address - Fax:517-787-7365
Practice Address - Street 1:1103 KALISTE SALOOM RD.
Practice Address - Street 2:SUITE 304
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508
Practice Address - Country:US
Practice Address - Phone:337-988-5646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX849661367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered