Individual
MR. TED ETELL FONTENOT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
ANP
Contact information
Practice address
1717 OAK PARK BLVD FL 2, LAKE CHARLES, LA 70601-8990
(337) 494-3278
(337) 494-3240
Mailing address
PO BOX 122152 DEPT 2152, DALLAS, TX 75312-0001
(337) 494-2921
(337) 494-6523
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
Primary
AP06448
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2159445
—
LA
01
—
AP06448
STATE LICENSE
LA
Enumeration date
07/06/2011
Last updated
04/27/2022
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