Healthcare Provider Details

I. General information

NPI: 1336160415
Provider Name (Legal Business Name): KRISTINE CLEARY FONTES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1374 W FRONTAGE RD
RIO RICO AZ
85648-6238
US

IV. Provider business mailing address

PO BOX 4168
TUBAC AZ
85646-4168
US

V. Phone/Fax

Practice location:
  • Phone: 520-281-8282
  • Fax: 520-377-0680
Mailing address:
  • Phone: 520-375-8283
  • Fax: 520-377-0680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP2066
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: