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General NPI Number Information
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NPI Number | 1700016359
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Entity Type | Individual
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Provider Name | KELLY FOUNTAIN M.D.
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Gender | Female
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Dates
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Enumeration Date | 07/16/2009
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Last Update Date | 05/10/2020
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Provider Practice Location Address
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Address Line | 1223 GATEWAY DR
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City | MELBOURNE
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State | FL
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Zip | 32901-2607
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Country | US
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Telephone | 321-728-6002
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Fax |
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Provider Business Mailing Address
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Address Line | 4020 TURKEY POINT DR
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City | MELBOURNE
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State | FL
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Zip | 32934-8584
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Country | US
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Telephone | 251-363-1745
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Fax |
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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 | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 23930
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 30719
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License Number State | AL
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | DR.0057830
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License Number State | CO
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Taxonomy #4
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 04-37158
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License Number State | KS
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Taxonomy #5
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | ME 129581
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License Number State | FL
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