Provider Demographics
NPI:1265806640
Name:FONTAINE, LAURIE
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 HOLTEN ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-1937
Mailing Address - Country:US
Mailing Address - Phone:781-913-4280
Mailing Address - Fax:
Practice Address - Street 1:61 HOLTEN ST UNIT 1
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-1937
Practice Address - Country:US
Practice Address - Phone:781-913-4280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-22
Last Update Date:2015-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2353314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility