Provider Demographics
NPI:1942422860
Name:FONTAINE, MARY ELIZABETH (MS,RPT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:MS,RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 WALLIS ROAD
Mailing Address - Street 2:
Mailing Address - City:RYE
Mailing Address - State:NH
Mailing Address - Zip Code:03870-2245
Mailing Address - Country:US
Mailing Address - Phone:603-964-8819
Mailing Address - Fax:
Practice Address - Street 1:654 WALLIS ROAD
Practice Address - Street 2:
Practice Address - City:RYE
Practice Address - State:NH
Practice Address - Zip Code:03870-2245
Practice Address - Country:US
Practice Address - Phone:603-964-8819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0806320Y0NH01OtherPHYSICAL THERAPIST
NH30003796Medicaid