Provider Demographics
NPI:1285331108
Name:FONTANA, OLIVIA NICOLE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:NICOLE
Last Name:FONTANA
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 1:7 PRESTON HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3359
Mailing Address - Country:US
Mailing Address - Phone:631-626-7627
Mailing Address - Fax:
Practice Address - Street 1:7 PRESTON HOLLOW CT
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3359
Practice Address - Country:US
Practice Address - Phone:631-505-0576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2024-05-14
Deactivation Date:2023-07-01
Deactivation Code:
Reactivation Date:2023-07-19
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist