Provider Demographics
NPI:1235907759
Name:FOUNTAIN, DEBORAH (RN)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 STATE HIGHWAY 310 STE 1
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1493
Mailing Address - Country:US
Mailing Address - Phone:315-386-2189
Mailing Address - Fax:315-386-2435
Practice Address - Street 1:80 ST HWY 310 STE 1
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1493
Practice Address - Country:US
Practice Address - Phone:315-386-2189
Practice Address - Fax:315-386-2435
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY564484163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty