Healthcare Provider Details

I. General information

NPI: 1831855865
Provider Name (Legal Business Name): JOSHUA SHANE FOUNTAIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2021
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3031
US

IV. Provider business mailing address

934 GARIBALDI ST SW
ATLANTA GA
30310-3134
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-1000
  • Fax:
Mailing address:
  • Phone: 470-967-4841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberRN247882
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: