Healthcare Provider Details

I. General information

NPI: 1194955757
Provider Name (Legal Business Name): PAMELA KINDER FOUNTAIN MSN, RNC, APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

7916 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

V. Phone/Fax

Practice location:
  • Phone: 260-434-7088
  • Fax: 260-435-7394
Mailing address:
  • Phone: 260-434-6377
  • Fax: 260-434-6389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number#71001329A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number#71001329A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number28108484A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: