Healthcare Provider Details

I. General information

NPI: 1538402144
Provider Name (Legal Business Name): CYNTHIA FOUNTAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2013
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST STE 302
BOISE ID
83712
US

IV. Provider business mailing address

100 E IDAHO ST STE 302
BOISE ID
83712-6269
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-7501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberM-15042
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: