Basic Information
| Provider Information | |||||||||
| NPI: | 1841287174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONTAINE | ||||||||
| FirstName: | NICOLETTE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARVIL | ||||||||
| OtherFirstName: | NICOLETTE | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 291 INDEPENDENCE DRIVE | ||||||||
| Address2: | INTERNAL MEDICINE | ||||||||
| City: | CHESTNUT HILL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175416625 | ||||||||
| FaxNumber: | 6175416444 | ||||||||
| Practice Location | |||||||||
| Address1: | 291 INDEPENDENCE DRIVE | ||||||||
| Address2: | INTERNAL MEDICINE | ||||||||
| City: | CHESTNUT HILL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175416625 | ||||||||
| FaxNumber: | 6175416444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 208376 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0151068 | 05 | MA | MEDICAID |