Provider Demographics
NPI:1053676726
Name:FOUNTAIN, KENDRA
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:FOUNTAIN
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 1:2628 DARIEN DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-7223
Mailing Address - Country:US
Mailing Address - Phone:812-725-0675
Mailing Address - Fax:
Practice Address - Street 1:2628 DARIEN DR
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-7223
Practice Address - Country:US
Practice Address - Phone:812-725-0675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator