Healthcare Provider Details

I. General information

NPI: 1861584005
Provider Name (Legal Business Name): BRIAN KENNETH FONTAINE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 AMARAL ST STE 100
RIVERSIDE RI
02915-2205
US

IV. Provider business mailing address

33 SCARBOROUGH RD
PAWTUCKET RI
02861-4022
US

V. Phone/Fax

Practice location:
  • Phone: 352-275-2064
  • Fax:
Mailing address:
  • Phone: 401-725-7021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN00008
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number241092
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: