Provider Demographics
NPI:1679200638
Name:FONTENOT, THEO ATLAS
Entity type:Individual
Prefix:
First Name:THEO
Middle Name:ATLAS
Last Name:FONTENOT
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:LINDSEY
Other - Middle Name:MARIE
Other - Last Name:O'NEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3001 HARVEST HILLS DR APT 315
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-2670
Mailing Address - Country:US
Mailing Address - Phone:701-705-0868
Mailing Address - Fax:
Practice Address - Street 1:3001 HARVEST HILLS DR APT 315
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-2670
Practice Address - Country:US
Practice Address - Phone:701-705-0868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2024-09-18
Deactivation Date:2024-09-03
Deactivation Code:
Reactivation Date:2024-09-18
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other