Basic Information
| Provider Information | |||||||||
| NPI: | 1477581965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONTAINE | ||||||||
| FirstName: | ANNIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 BANDANA BLVD E | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551085113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516422700 | ||||||||
| FaxNumber: | 6516429441 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 BANDANA BLVD W | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551085107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516417021 | ||||||||
| FaxNumber: | 6516417151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 37625 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 786018800 | 05 | MN | MEDICAID |