Provider Demographics
NPI:1306004965
Name:FOUNTAIN, MIMI M (NCBTMB, RN)
Entity Type:Individual
Prefix:MRS
First Name:MIMI
Middle Name:M
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:NCBTMB, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 WATERFALL LN
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-3741
Mailing Address - Country:US
Mailing Address - Phone:970-759-8872
Mailing Address - Fax:
Practice Address - Street 1:1005 WATERFALL LN
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-3741
Practice Address - Country:US
Practice Address - Phone:970-759-8872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL441885-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist