MEDICARE: BROOKE ERIN FOUNTAIN FNP-BC

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	363LF0000X	Family Nurse Practitioner	AP140756	TX

General Provider Information

NPI Number	:	1790344000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE ERIN FOUNTAIN FNP-BC

Provider Business Mailing Address
First Line	:	6257 FM 2642 BLVD
Second Line	:
City	:	ROYSE CITY
State	:	TX
Zip	:	75189-3223
Country	:	US
Telephone Number	:	469-800-3670
Fax Number	:

Provider Business Practice Location Address
First Line	:	6257 FM 2642 BLVD
Second Line	:
City	:	ROYSE CITY
State	:	TX
Zip	:	75189-3223
Country	:	US
Telephone Number	:	469-800-3670
Fax Number	:

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

Provider Enumeration Date	:	06/10/2019
Last Update Date	:	01/23/2023

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