Provider Demographics
NPI:1467629428
Name:FONTAINE, SUSAN BETH (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:BETH
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:CRNP
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:750 5TH AVE E
Mailing Address - Street 2:UA STUDENT HEALTH CENTER
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-7421
Mailing Address - Country:US
Mailing Address - Phone:205-348-6262
Mailing Address - Fax:205-648-8611
Practice Address - Street 1:750 5TH AVE E
Practice Address - Street 2:UA STUDENT HEALTH CENTER
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-7421
Practice Address - Country:US
Practice Address - Phone:205-348-6262
Practice Address - Fax:205-648-8611
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-048688363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALR89045Medicare UPIN