MEDICARE: JOANNE ELLEN FOUNTAINE LPN

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	164W00000X	Licensed Practical Nurse	114453	OH
2	164W00000X	Licensed Practical Nurse	L41519-0	MN

General Provider Information

NPI Number	:	1346573433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANNE ELLEN FOUNTAINE LPN

Provider Business Mailing Address
First Line	:	8414 WASHINGTON VILLAGE DR
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45458-1845
Country	:	US
Telephone Number	:	937-248-9349
Fax Number	:

Provider Business Practice Location Address
First Line	:	8414 WASHINGTON VILLAGE DR
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45458-1845
Country	:	US
Telephone Number	:	937-248-9349
Fax Number	:

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

Provider Enumeration Date	:	09/08/2009
Last Update Date	:	09/08/2009

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