Provider Demographics
NPI:1083597876
Name:FOUNTAIN, CYNTHIA ANN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 ROLLO DOMINO CIR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3485
Mailing Address - Country:US
Mailing Address - Phone:706-750-8617
Mailing Address - Fax:
Practice Address - Street 1:909 ROLLO DOMINO CIR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3485
Practice Address - Country:US
Practice Address - Phone:706-814-0705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN174712163W00000X, 363LP0808X
171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No171400000XOther Service ProvidersHealth & Wellness Coach