Provider Demographics
NPI:1194756965
Name:FONTAINE, ANN MEYER (PAC)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MEYER
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:NICHOLSON
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:5500 ARMSTRONG RD
Mailing Address - Street 2:VAMC
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49037-7314
Mailing Address - Country:US
Mailing Address - Phone:269-966-5600
Mailing Address - Fax:
Practice Address - Street 1:5500 ARMSTRONG RD
Practice Address - Street 2:VAMC
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037-7314
Practice Address - Country:US
Practice Address - Phone:269-966-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002311363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP35450016Medicare PIN