Provider Demographics
NPI:1578855326
Name:FOUNTAIN, DANIELLE (LMT, NCTMB, MMP)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:LMT, NCTMB, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DUPONT LN
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-3208
Mailing Address - Country:US
Mailing Address - Phone:904-347-1855
Mailing Address - Fax:
Practice Address - Street 1:212 SAN MARCO AVE STE C
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-2771
Practice Address - Country:US
Practice Address - Phone:904-347-1855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA48413225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist