Provider Demographics
NPI:1376205625
Name:FOUNTAINE, KATHRYN NICHOLE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:NICHOLE
Last Name:FOUNTAINE
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 1:384 DEVON DR
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-1781
Mailing Address - Country:US
Mailing Address - Phone:484-886-5033
Mailing Address - Fax:
Practice Address - Street 1:421 CHEW ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18102-3406
Practice Address - Country:US
Practice Address - Phone:866-785-8537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062937363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical