Basic Information
Provider Information | |||||||||
NPI: | 1134598659 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FOUNTAIN | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | MICHELE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BROWN | ||||||||
OtherFirstName: | ANGELA | ||||||||
OtherMiddleName: | MICHELE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 830 KEMPSVILLE RD 2B223 | ||||||||
Address2: |   | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235023920 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572618860 | ||||||||
FaxNumber: | 7576892420 | ||||||||
Practice Location | |||||||||
Address1: | 830 KEMPSVILLE RD | ||||||||
Address2: |   | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235023920 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572616700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2015 | ||||||||
LastUpdateDate: | 11/09/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0024172983 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.