Provider Demographics
NPI:1477193803
Name:FONTAINE, NICHOLE THERESA (CARC)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:THERESA
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:CARC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4111
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02723-0400
Mailing Address - Country:US
Mailing Address - Phone:774-704-5501
Mailing Address - Fax:
Practice Address - Street 1:1507 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02723-1914
Practice Address - Country:US
Practice Address - Phone:774-704-5501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator