Healthcare Provider Details

I. General information

NPI: 1760559314
Provider Name (Legal Business Name): JAMES DAVID FOUNTAIN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3827 S SWEET ESCAPE DR
WASHINGTON UT
84780-3003
US

IV. Provider business mailing address

3827 S SWEET ESCAPE DR
WASHINGTON UT
84780-3003
US

V. Phone/Fax

Practice location:
  • Phone: 904-403-8967
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP3245982
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number10166914-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: