Provider Demographics
NPI:1235271594
Name:FONTAINE, TAMIKA (P T)
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18602 ACCOKEEK CT
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-3274
Mailing Address - Country:US
Mailing Address - Phone:443-523-6066
Mailing Address - Fax:
Practice Address - Street 1:70 VILLAGE ST
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-1838
Practice Address - Country:US
Practice Address - Phone:301-645-2776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20126225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist