Provider Demographics
NPI:1073748273
Name:FOUNTAIN, AMIKO SUE (DC)
Entity Type:Individual
Prefix:DR
First Name:AMIKO
Middle Name:SUE
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13660 N 94TH DR STE C4
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4841
Mailing Address - Country:US
Mailing Address - Phone:602-502-2319
Mailing Address - Fax:
Practice Address - Street 1:1950 SPECTRUM CIR SE STE 400
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-1638
Practice Address - Country:US
Practice Address - Phone:678-541-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008451111N00000X
AZ8118111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor