Provider Demographics
NPI:1497072060
Name:FONTAINE, MADELINE (LMT)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 PARKBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-8913
Mailing Address - Country:US
Mailing Address - Phone:850-294-1928
Mailing Address - Fax:
Practice Address - Street 1:3521 MACLAY BLVD S
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-3913
Practice Address - Country:US
Practice Address - Phone:850-431-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-22
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA56297171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC106YOtherBLUECROSS BLUESHIELD OF FLORIDA