Individual provider · NPI-1

Elissa Gloria Fontenot, NP

Nurse Practitioner · Lithonia, GA

NPI number1386229839

StatusActive

Last updated in NPPESMar 16, 2021

Details

NPI: 1386229839
Entity type: Individual (NPI-1)
Name: Elissa Gloria Fontenot
Credential: NP
Sex: Female
Sole proprietor: No
Enumeration date: Mar 16, 2021
Certification date: Feb 16, 2021
Last updated: Mar 16, 2021

Taxonomy and licenses

Taxonomy code	Description	License	State	Primary
363L00000X	Nurse Practitioner	NCO-000003	GA	Yes
163WG0000X	Registered Nurse, General Practice	RN241909	GA

Practice location

2801 Dekalb Medical Pkwy
Lithonia, GA 30058-4996

Phone 404-501-8000

Mailing address

105 Princeton Ct
Covington, GA 30016-2953

Phone 678-793-3123

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