Healthcare Provider Details

I. General information

NPI: 1518202811
Provider Name (Legal Business Name): JANENE P. FONTAINE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2012
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6219 S HAVEN CHASE LN
SALT LAKE CITY UT
84121
US

IV. Provider business mailing address

6219 S HAVEN CHASE LN
SALT LAKE CITY UT
84121-6512
US

V. Phone/Fax

Practice location:
  • Phone: 801-450-0909
  • Fax:
Mailing address:
  • Phone: 801-450-0909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7999353-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: