Provider Demographics
NPI:1053042994
Name:FONTAINE, PHARA BRITNEY
Entity Type:Individual
Prefix:MS
First Name:PHARA
Middle Name:BRITNEY
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02723-2447
Mailing Address - Country:US
Mailing Address - Phone:508-840-5520
Mailing Address - Fax:
Practice Address - Street 1:478 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02723-2447
Practice Address - Country:US
Practice Address - Phone:508-840-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist