Provider Demographics
NPI:1063122612
Name:FOUNTAIN, SARAH KAY
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:KAY
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:KAY
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:970 LAKELAND DR STE 61
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4634
Mailing Address - Country:US
Mailing Address - Phone:601-405-3690
Mailing Address - Fax:
Practice Address - Street 1:970 LAKELAND DR STE 61
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4634
Practice Address - Country:US
Practice Address - Phone:601-982-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905690363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily