Provider Demographics
NPI:1538680996
Name:FOUNTAIN, KRYSTAL LYNNETTE
Entity Type:Individual
Prefix:MISS
First Name:KRYSTAL
Middle Name:LYNNETTE
Last Name:FOUNTAIN
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 1:7806 S WOOD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-4446
Mailing Address - Country:US
Mailing Address - Phone:773-633-7466
Mailing Address - Fax:
Practice Address - Street 1:7806 S WOOD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-4446
Practice Address - Country:US
Practice Address - Phone:773-633-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist