Provider Demographics
NPI:1962865220
Name:FONTAINE, DANIELLE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5221 PARAMOUNT PKWY STE 420
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-5491
Mailing Address - Country:US
Mailing Address - Phone:984-974-2705
Mailing Address - Fax:
Practice Address - Street 1:730 MALCOLM BLVD
Practice Address - Street 2:
Practice Address - City:CONNELLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28612-8079
Practice Address - Country:US
Practice Address - Phone:828-580-3572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-03
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022031705208600000X
390200000X
NC2019-00201208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program