Provider Demographics
NPI:1346573433
Name:FOUNTAINE, JOANNE ELLEN (LPN)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:ELLEN
Last Name:FOUNTAINE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8414 WASHINGTON VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-1845
Mailing Address - Country:US
Mailing Address - Phone:937-248-9349
Mailing Address - Fax:
Practice Address - Street 1:8414 WASHINGTON VILLAGE DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-1845
Practice Address - Country:US
Practice Address - Phone:937-248-9349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH114453164W00000X
MNL41519-0164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse