Provider Demographics
NPI:1124441043
Name:FONTAINE, DE ADREA DISHONNA (ND)
Entity type:Individual
Prefix:DR
First Name:DE ADREA
Middle Name:DISHONNA
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 E RAY RD STE 110
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4202
Mailing Address - Country:US
Mailing Address - Phone:480-666-5505
Mailing Address - Fax:469-619-3245
Practice Address - Street 1:633 E RAY RD STE 110
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4202
Practice Address - Country:US
Practice Address - Phone:480-666-5505
Practice Address - Fax:469-619-3245
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13-1415175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath