Provider Demographics
NPI:1174906689
Name:FONTANES, ELBA I (ND)
Entity type:Individual
Prefix:MS
First Name:ELBA
Middle Name:
Last Name:FONTANES
Suffix:I
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:ELBA
Other - Middle Name:
Other - Last Name:MALDONADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ND
Mailing Address - Street 1:4701 PARK EDEN CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-1907
Mailing Address - Country:US
Mailing Address - Phone:407-970-4186
Mailing Address - Fax:
Practice Address - Street 1:832 W CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-1809
Practice Address - Country:US
Practice Address - Phone:407-836-7109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 3421133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered