Basic Information
| Provider Information | |||||||||
| NPI: | 1578141024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOUNTAIN | ||||||||
| FirstName: | EDNITA | ||||||||
| MiddleName: | CHARZETTE STREET | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNP, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3157 BASIN REFUGE RD | ||||||||
| Address2: | |||||||||
| City: | LUCEDALE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394527688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019470366 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1421 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478071005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122314608 | ||||||||
| FaxNumber: | 8122314675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2021 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 889173 | MS | N | Nursing Service Providers | Registered Nurse | 367500000X | 901702 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.