Provider Demographics
NPI:1639687437
Name:FONTAINE, THERESA D (NP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:D
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 S 74TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5156
Mailing Address - Country:US
Mailing Address - Phone:314-364-7595
Mailing Address - Fax:
Practice Address - Street 1:201 S 7TH ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AR
Practice Address - Zip Code:72949-3131
Practice Address - Country:US
Practice Address - Phone:479-667-1590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005460363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner