Healthcare Provider Details

I. General information

NPI: 1255952040
Provider Name (Legal Business Name): GRACIEUSE FONTAINE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2020
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 FLOYD ST
BRENTWOOD NY
11717-2647
US

IV. Provider business mailing address

134 FLOYD ST
BRENTWOOD NY
11717-2647
US

V. Phone/Fax

Practice location:
  • Phone: 631-855-2787
  • Fax:
Mailing address:
  • Phone: 631-855-2787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number870650
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: