Provider Demographics
NPI:1619375110
Name:FONTAINE, SHAUNDRA RENEE (RN, APRN, CNM)
Entity Type:Individual
Prefix:MS
First Name:SHAUNDRA
Middle Name:RENEE
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:RN, APRN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5989
Mailing Address - Country:US
Mailing Address - Phone:208-343-2079
Mailing Address - Fax:208-343-6828
Practice Address - Street 1:207 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5989
Practice Address - Country:US
Practice Address - Phone:208-343-2079
Practice Address - Fax:208-343-6828
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDA-80367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCNM-80AOtherADVANCED PRACTICE LICENSE