Provider Demographics
NPI:1437185402
Name:FONTAINE, HEATHER LEIGH
Entity Type:Individual
Prefix:MISS
First Name:HEATHER
Middle Name:LEIGH
Last Name:FONTAINE
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 1:854 WRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-2836
Mailing Address - Country:US
Mailing Address - Phone:330-821-4926
Mailing Address - Fax:
Practice Address - Street 1:854 WRIGHT AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-2836
Practice Address - Country:US
Practice Address - Phone:330-821-4926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2497301Medicaid