Provider Demographics
NPI:1659402832
Name:FOUNTAIN, HALEY C
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:C
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 S MANUFACTURERS ROW
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:TN
Mailing Address - Zip Code:38382-3632
Mailing Address - Country:US
Mailing Address - Phone:731-855-7601
Mailing Address - Fax:731-855-7603
Practice Address - Street 1:1250 S MANUFACTURERS ROW
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:TN
Practice Address - Zip Code:38382-3632
Practice Address - Country:US
Practice Address - Phone:731-855-7601
Practice Address - Fax:731-855-7603
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000142339163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse