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1578141024 NPI number — EDNITA CHARZETTE STREET FOUNTAIN DNP, CRNA

NPI Number: 1578141024
Health Care Provider/Practitioner: EDNITA CHARZETTE STREET FOUNTAIN DNP, CRNA

Information about “1578141024” NPI (EDNITA CHARZETTE STREET FOUNTAIN DNP, CRNA) exists in 1578141024 in HTML format HTML  |  1578141024 in plain Text format TXT  |  1578141024 in PDF (Portable Document Format) PDF  |  1578141024 in an XML format XML  formats.

NPI Number : 1578141024 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1578141024",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "FOUNTAIN",
    "FirstName": "EDNITA",
    "MiddleName": "CHARZETTE STREET",
    "NamePrefix": "DR.",
    "NameSuffix": null,
    "Credential": "DNP, CRNA",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "3157 BASIN REFUGE RD",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "LUCEDALE",
    "MailingAddressStateName": "MS",
    "MailingAddressPostalCode": "39452-7688",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "601-947-0366",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "1421 N 7TH ST",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "TERRE HAUTE",
    "PracticeLocationAddressStateName": "IN",
    "PracticeLocationAddressPostalCode": "47807-1005",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "812-231-4608",
    "PracticeLocationAddressFaxNumber": "812-231-4675",
    "EnumerationDate": "03/29/2021",
    "LastUpdateDate": "06/16/2021",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "163W00000X",
          "TaxonomyName": "Registered Nurse",
          "LicenseNumber": "889173",
          "LicenseNumberStateCode": "MS",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "367500000X",
          "TaxonomyName": "Certified Registered Nurse Anesthetist",
          "LicenseNumber": "901702",
          "LicenseNumberStateCode": "MS",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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