Provider Demographics
NPI:1811712136
Name:FONTAINE, MADISON RAE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:RAE
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 8TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-4516
Mailing Address - Country:US
Mailing Address - Phone:701-415-8938
Mailing Address - Fax:
Practice Address - Street 1:1309 8TH AVE SE
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-4516
Practice Address - Country:US
Practice Address - Phone:701-415-8938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty