Provider Demographics
NPI:1699213496
Name:FOUNTAIN, LAURA JEAN (CPNP-PC)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:JEAN
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E PEARSON ST APT 2407
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-7367
Mailing Address - Country:US
Mailing Address - Phone:954-557-3246
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN250573363LP0200X
IL209.018082363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics