Provider Demographics
NPI:1194955757
Name:FOUNTAIN, PAMELA KINDER (MSN, RNC, APRN-BC)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:KINDER
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:MSN, RNC, APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7916 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-434-6377
Mailing Address - Fax:260-434-6389
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-434-7088
Practice Address - Fax:260-435-7394
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN#71001329A363LF0000X, 363LG0600X
IN28108484A163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201006320Medicaid
IN201006320Medicaid