Provider Demographics
NPI:1487176764
Name:FOUNTAIN, LEAH DANIELLE (MSN, NP-C APRN)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:DANIELLE
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:MSN, NP-C APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1254
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-1254
Mailing Address - Country:US
Mailing Address - Phone:870-425-8288
Mailing Address - Fax:
Practice Address - Street 1:555 W 6TH ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3409
Practice Address - Country:US
Practice Address - Phone:870-425-8288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-08
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005203363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily