Provider Demographics
NPI:1265193510
Name:FONTAINE, RITA ILSE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:RITA
Middle Name:ILSE
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1404 WATERWINDS CT
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6270
Mailing Address - Country:US
Mailing Address - Phone:919-619-0167
Mailing Address - Fax:
Practice Address - Street 1:13271 STRICKLAND RD STE 120
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-5228
Practice Address - Country:US
Practice Address - Phone:919-741-4677
Practice Address - Fax:919-741-6349
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC0010-12549363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program