Individual
MARY NECOLOA FONTENOT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1324 ROSETTA ST, LAKE CHARLES, LA 70607-1932
(337) 912-8617
Mailing address
1324 ROSETTA ST, LAKE CHARLES, LA 70607-1932
(337) 912-8617
Taxonomy
Speciality
Code
Description
License number
State
171WV0202X
Vehicle Modifications Contractor
Primary
008907424
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
882717925
—
LA
Enumeration date
03/19/2018
Last updated
03/19/2018
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