Provider Demographics
NPI:1073023115
Name:FOUNTAIN, MICHAEL MCKINLEY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MCKINLEY
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79-1019 HAUKAPILA ST
Mailing Address - Street 2:
Mailing Address - City:KEALAKEKUA
Mailing Address - State:HI
Mailing Address - Zip Code:96750-7920
Mailing Address - Country:US
Mailing Address - Phone:808-322-9311
Mailing Address - Fax:478-296-2801
Practice Address - Street 1:79-1019 HAUKAPILA ST
Practice Address - Street 2:
Practice Address - City:KEALAKEKUA
Practice Address - State:HI
Practice Address - Zip Code:96750-7920
Practice Address - Country:US
Practice Address - Phone:808-322-9311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN240666363LF0000X
HIAPRN-2633-0363LF0000X
HIAPRN-2633363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily