Provider Demographics
NPI:1073924460
Name:FOUNTAIN, CHANICA LYNNA
Entity Type:Individual
Prefix:
First Name:CHANICA
Middle Name:LYNNA
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 1:6700 SHEFFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-5449
Mailing Address - Country:US
Mailing Address - Phone:702-788-3216
Mailing Address - Fax:
Practice Address - Street 1:6700 SHEFFIELD DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-5449
Practice Address - Country:US
Practice Address - Phone:702-788-3216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor