Provider Demographics
NPI:1043196348
Name:FOUNTAIN, KRISTA WILSON (OTR/L)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:WILSON
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:LYNN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:168 RIDGEWOOD PARK DR S
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-1167
Mailing Address - Country:US
Mailing Address - Phone:912-429-9583
Mailing Address - Fax:912-429-9583
Practice Address - Street 1:1 PEACHTREE DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1200
Practice Address - Country:US
Practice Address - Phone:912-927-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004975225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist