Provider Demographics
NPI:1043855893
Name:FOUNTAIN, DORELLA NICOLE
Entity Type:Individual
Prefix:
First Name:DORELLA
Middle Name:NICOLE
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DORELLA
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6107 BREEZEWOOD CT APT 303
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-1114
Mailing Address - Country:US
Mailing Address - Phone:240-840-6976
Mailing Address - Fax:
Practice Address - Street 1:248 58TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-6847
Practice Address - Country:US
Practice Address - Phone:202-250-0535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant