Provider Demographics
NPI:1487203675
Name:FONTES, GAIL (RN)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:FONTES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 CLARENDON AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4647
Mailing Address - Country:US
Mailing Address - Phone:330-605-7865
Mailing Address - Fax:
Practice Address - Street 1:116 CLARENDON AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-4647
Practice Address - Country:US
Practice Address - Phone:330-605-7865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH360598163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH284729393Medicaid