Healthcare Provider Details

I. General information

NPI: 1265193510
Provider Name (Legal Business Name): RITA ILSE FONTAINE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13271 STRICKLAND RD STE 120
RALEIGH NC
27613-5228
US

IV. Provider business mailing address

PO BOX 96860
CHARLOTTE NC
28296-6860
US

V. Phone/Fax

Practice location:
  • Phone: 919-741-4677
  • Fax: 919-741-6349
Mailing address:
  • Phone: 919-761-5678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-12549
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: