Provider Demographics
NPI:1700276821
Name:FONTAINE, RILEY NEAN (MSAT, ATC, OTC)
Entity Type:Individual
Prefix:MISS
First Name:RILEY
Middle Name:NEAN
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:MSAT, ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 ROEBLING LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1868
Mailing Address - Country:US
Mailing Address - Phone:802-309-0450
Mailing Address - Fax:
Practice Address - Street 1:230 CLEARFIELD AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:757-321-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260021712255A2300X, 207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
16-0804OtherORTHOPAEDIC TECHNOLOGIST CERTIFICATION