Provider Demographics
NPI:1093418477
Name:FONTAINE-FANFAN, VELINE
Entity Type:Individual
Prefix:MS
First Name:VELINE
Middle Name:
Last Name:FONTAINE-FANFAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:VELINE
Other - Middle Name:
Other - Last Name:FONTAINE-FANFAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:265 BROADHOLLOW RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4833
Mailing Address - Country:US
Mailing Address - Phone:631-592-5018
Mailing Address - Fax:
Practice Address - Street 1:265 BROADHOLLOW RD STE 200
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4833
Practice Address - Country:US
Practice Address - Phone:631-592-5018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY636074163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse