Provider Demographics
NPI:1639105828
Name:FONTAINE, DEBRA (CRNA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:
Other - Last Name:STEGALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:SUITE # 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:703-766-9737
Mailing Address - Fax:
Practice Address - Street 1:850 ENTERPRISE PKWY
Practice Address - Street 2:SUITE # 1000
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666
Practice Address - Country:US
Practice Address - Phone:757-594-2000
Practice Address - Fax:757-594-3005
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN49062367500000X
FLARNP9255984367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT328400YRNMedicare PIN