Provider Demographics
NPI:1134092570
Name:FONTAINE, MANITA
Entity type:Individual
Prefix:
First Name:MANITA
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13506 N ROME AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-2027
Mailing Address - Country:US
Mailing Address - Phone:813-389-5421
Mailing Address - Fax:
Practice Address - Street 1:13506 N ROME AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2027
Practice Address - Country:US
Practice Address - Phone:813-389-5421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5197301164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty