Provider Demographics
NPI:1386941862
Name:FOUNTAIN, KAREENA ANGELA (LMP)
Entity type:Individual
Prefix:MS
First Name:KAREENA
Middle Name:ANGELA
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17719 JORDAN ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:WA
Mailing Address - Zip Code:98579-8533
Mailing Address - Country:US
Mailing Address - Phone:360-359-2736
Mailing Address - Fax:360-273-5809
Practice Address - Street 1:17719 JORDAN ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:WA
Practice Address - Zip Code:98579-8533
Practice Address - Country:US
Practice Address - Phone:360-359-2736
Practice Address - Fax:360-273-5809
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601686008174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist