MEDICARE: DR. DE ADREA DISHONNA FONTAINE ND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175F00000X	Naturopath	13-1415	AZ

General Provider Information

NPI Number	:	1124441043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DE ADREA DISHONNA FONTAINE ND

Provider Business Mailing Address
First Line	:	633 E RAY RD STE 110
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85296-4202
Country	:	US
Telephone Number	:	480-666-5505
Fax Number	:	469-619-3245

Provider Business Practice Location Address
First Line	:	633 E RAY RD STE 110
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85296-4202
Country	:	US
Telephone Number	:	480-666-5505
Fax Number	:	469-619-3245

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2014
Last Update Date	:	01/29/2014

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Directions to “ DR. DE ADREA DISHONNA FONTAINE ND” Practice Location

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