Provider Demographics
NPI:1447485107
Name:FONTENOT, HOLLY BURRIS (RN, MS, WHNP-BC)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:BURRIS
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:RN, MS, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BOYLSTON ST
Mailing Address - Street 2:SIDNEY BORUM HEALTH CENTER
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-4608
Mailing Address - Country:US
Mailing Address - Phone:617-457-8140
Mailing Address - Fax:
Practice Address - Street 1:130 BOYLSTON ST
Practice Address - Street 2:SIDNEY BORUM HEALTH CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-4608
Practice Address - Country:US
Practice Address - Phone:617-457-8140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226670363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health