Provider Demographics
NPI:1417230509
Name:SADLAK, FONTAINE
Entity Type:Individual
Prefix:MRS
First Name:FONTAINE
Middle Name:
Last Name:SADLAK
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 1:3760 ULLA LN
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-5341
Mailing Address - Country:US
Mailing Address - Phone:951-907-7244
Mailing Address - Fax:
Practice Address - Street 1:3132 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4421
Practice Address - Country:US
Practice Address - Phone:760-910-6217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260620164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse