Provider Demographics
NPI:1629691225
Name:FOUNTAIN, JULIANNE KAY (ARNP, PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:JULIANNE
Middle Name:KAY
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:ARNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 MAHAN CENTER BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5476
Mailing Address - Country:US
Mailing Address - Phone:850-999-2996
Mailing Address - Fax:
Practice Address - Street 1:1618 MAHAN CENTER BLVD STE 103
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5476
Practice Address - Country:US
Practice Address - Phone:850-999-2996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007968363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11007968OtherDEPARTMENT OF HEALTH LICENSE NUMBER