1467629428 NPI number — MRS. SUSAN BETH FONTAINE CRNP

Table of content: MRS. SUSAN BETH FONTAINE CRNP (NPI 1467629428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467629428 NPI number — MRS. SUSAN BETH FONTAINE CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONTAINE
Provider First Name:
SUSAN
Provider Middle Name:
BETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467629428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 5TH AVE E
Provider Second Line Business Mailing Address:
UA STUDENT HEALTH CENTER
Provider Business Mailing Address City Name:
TUSCALOOSA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35401-7421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-348-6262
Provider Business Mailing Address Fax Number:
205-648-8611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 5TH AVE E
Provider Second Line Business Practice Location Address:
UA STUDENT HEALTH CENTER
Provider Business Practice Location Address City Name:
TUSCALOOSA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35401-7421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-348-6262
Provider Business Practice Location Address Fax Number:
205-648-8611
Provider Enumeration Date:
05/09/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  1-048688 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)