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General NPI Number Information
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NPI Number | 1548671472
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Entity Type | Individual
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Provider Name | KATIE DIANA FOUNTAIN PA-C
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Gender | Female
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Dates
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Enumeration Date | 05/14/2014
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Last Update Date | 11/05/2025
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Provider Practice Location Address
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Address Line | 1825 MARTHA BERRY BLVD NW
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City | ROME
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State | GA
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Zip | 30165-1625
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Country | US
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Telephone | 706-295-5331
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Fax | 706-235-3104
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Provider Business Mailing Address
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Address Line | PO BOX 911589
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City | DENVER
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State | CO
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Zip | 80291-1589
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Country | US
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Telephone | 505-923-6100
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Fax | 505-923-6698
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 007228
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0010-08451
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA.1620
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License Number State | AL
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