Provider Demographics
NPI:1629432216
Name:CLAIRVIL FONTAINE, MONA (NP)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:
Last Name:CLAIRVIL FONTAINE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:MONA
Other - Middle Name:CLAIRVIL
Other - Last Name:FONTAINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:3206 SABLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-7683
Mailing Address - Country:US
Mailing Address - Phone:470-326-3303
Mailing Address - Fax:
Practice Address - Street 1:3206 SABLE RIDGE DR
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-7683
Practice Address - Country:US
Practice Address - Phone:470-326-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN177893363L00000X, 363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care