Basic Information
| Provider Information | |||||||||
| NPI: | 1265193510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONTAINE | ||||||||
| FirstName: | RITA | ||||||||
| MiddleName: | ILSE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1404 WATERWINDS CT | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275876270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196190167 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13271 STRICKLAND RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276135228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197414677 | ||||||||
| FaxNumber: | 9197416349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2022 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | 0010-12549 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.