Provider Demographics
NPI:1548971252
Name:FONTAN, KENNETH JR (NBC-HWC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:FONTAN
Suffix:JR
Gender:M
Credentials:NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 PLOVER AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-4348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1071 PLOVER AVE
Practice Address - Street 2:
Practice Address - City:MIAMI SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33166-4348
Practice Address - Country:US
Practice Address - Phone:305-915-4933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
A-3528385171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach