Provider Demographics
NPI:1194416230
Name:FONTAINE, DIANNE
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:
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 1:9600 GAYLORD PKWY APT 1317
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-6133
Mailing Address - Country:US
Mailing Address - Phone:115-167-5425
Mailing Address - Fax:
Practice Address - Street 1:9600 GAYLORD PKWY APT 1317
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-6133
Practice Address - Country:US
Practice Address - Phone:115-167-5425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025486363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health