Healthcare Provider Details

I. General information

NPI: 1235046020
Provider Name (Legal Business Name): LAURY MARLEN FONTAINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 E 20TH ST
NORTH LITTLE ROCK AR
72114-2923
US

IV. Provider business mailing address

213 E 20TH ST
NORTH LITTLE ROCK AR
72114-2923
US

V. Phone/Fax

Practice location:
  • Phone: 501-355-2809
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: