Provider Demographics
NPI:1558122473
Name:FONTAINE, DOMINIQUE (RN, HNB-BC, HWNC-BC)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:RN, HNB-BC, HWNC-BC
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 331074
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96733-1074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3681 BALDWIN AVE STE G-102
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-7505
Practice Address - Country:US
Practice Address - Phone:808-707-0925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9576272163WN0800X
HIRN-114233-0364SH1100X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience
No364SH1100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHolistic