Provider Demographics
NPI:1578141024
Name:FOUNTAIN, EDNITA CHARZETTE STREET (DNP, CRNA)
Entity Type:Individual
Prefix:DR
First Name:EDNITA
Middle Name:CHARZETTE STREET
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3157 BASIN REFUGE RD
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-7688
Mailing Address - Country:US
Mailing Address - Phone:601-947-0366
Mailing Address - Fax:
Practice Address - Street 1:1421 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1005
Practice Address - Country:US
Practice Address - Phone:812-231-4608
Practice Address - Fax:812-231-4675
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS889173163W00000X
MS901702367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse