Provider Demographics
NPI:1255776308
Name:FOUNTAIN, ANGELA L (CRNA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6433 S CLARK DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-3308
Mailing Address - Country:US
Mailing Address - Phone:480-414-1295
Mailing Address - Fax:
Practice Address - Street 1:6433 S CLARK DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3308
Practice Address - Country:US
Practice Address - Phone:480-414-1295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0926367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ163652Medicare UPIN