Provider Demographics
NPI:1912533811
Name:FONTAINE, NICOLE JUSTINE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:JUSTINE
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:JUSTINE
Other - Last Name:DREGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19 MEG WAY
Mailing Address - Street 2:
Mailing Address - City:WINDSOR LOCKS
Mailing Address - State:CT
Mailing Address - Zip Code:06096-1263
Mailing Address - Country:US
Mailing Address - Phone:860-941-9744
Mailing Address - Fax:
Practice Address - Street 1:181 PATRICIA M GENOVA DR
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-1500
Practice Address - Country:US
Practice Address - Phone:860-696-2500
Practice Address - Fax:860-696-2525
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer