Provider Demographics
NPI:1235748369
Name:FOUNTAIN, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
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 1:1715 W EAGLE TALON TRL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5344
Mailing Address - Country:US
Mailing Address - Phone:602-309-1313
Mailing Address - Fax:
Practice Address - Street 1:25700 N. 21ST AVENUE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085
Practice Address - Country:US
Practice Address - Phone:623-445-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist