Provider Demographics
NPI:1952911489
Name:FOUNTAIN, STEPHANIE ANN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:FOUNTAIN
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 1:721 RAWHIDE RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WY
Mailing Address - Zip Code:82636-9708
Mailing Address - Country:US
Mailing Address - Phone:307-267-1703
Mailing Address - Fax:
Practice Address - Street 1:254 N CENTER ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1927
Practice Address - Country:US
Practice Address - Phone:307-267-1703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist