Healthcare Provider Details

I. General information

NPI: 1467629428
Provider Name (Legal Business Name): SUSAN BETH FONTAINE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 5TH AVE E UA STUDENT HEALTH CENTER
TUSCALOOSA AL
35401-7421
US

IV. Provider business mailing address

750 5TH AVE E UA STUDENT HEALTH CENTER
TUSCALOOSA AL
35401-7421
US

V. Phone/Fax

Practice location:
  • Phone: 205-348-6262
  • Fax: 205-648-8611
Mailing address:
  • Phone: 205-348-6262
  • Fax: 205-648-8611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-048688
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: