Provider Demographics
NPI:1679592950
Name:FOUNTAIN, KRISTIN J
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:J
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:PO BOX 505
Mailing Address - Street 2:413 MORRIS ST
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-0505
Mailing Address - Country:US
Mailing Address - Phone:360-466-7458
Mailing Address - Fax:360-466-1418
Practice Address - Street 1:413 MORRIS ST
Practice Address - Street 2:
Practice Address - City:LACONNER
Practice Address - State:WA
Practice Address - Zip Code:98257
Practice Address - Country:US
Practice Address - Phone:360-466-7458
Practice Address - Fax:360-466-1418
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008144225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8401291Medicaid
WA8806289Medicare ID - Type UnspecifiedPHYSICAL THERAPIST