Provider Demographics
NPI:1669570917
Name:LAFONTAINE, ANN CAROLINE (MA, RD, LD)
Entity type:Individual
Prefix:MRS
First Name:ANN
Middle Name:CAROLINE
Last Name:LAFONTAINE
Suffix:
Gender:F
Credentials:MA, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11563 BIG CANOE
Mailing Address - Street 2:4054 SOARING HAWK CIRCLE
Mailing Address - City:BIG CANOE
Mailing Address - State:GA
Mailing Address - Zip Code:30143-5115
Mailing Address - Country:US
Mailing Address - Phone:706-579-1992
Mailing Address - Fax:866-900-4295
Practice Address - Street 1:11563 BIG CANOE
Practice Address - Street 2:4054 SOARING HAWK CIRCLE
Practice Address - City:BIG CANOE
Practice Address - State:GA
Practice Address - Zip Code:30143-5115
Practice Address - Country:US
Practice Address - Phone:706-579-1992
Practice Address - Fax:866-900-4295
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000961133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered