Healthcare Provider Details

I. General information

NPI: 1417862160
Provider Name (Legal Business Name): FONTAINE E WEEDON LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 LEGENDS LN
LEXINGTON KY
40505-3484
US

IV. Provider business mailing address

6600 MAN O WAR BLVD APT 11304
LEXINGTON KY
40509-8814
US

V. Phone/Fax

Practice location:
  • Phone: 240-439-7818
  • Fax:
Mailing address:
  • Phone: 240-439-7818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT2317
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: