Provider Demographics
NPI:1538530688
Name:FONTAINE, VINCIA
Entity type:Individual
Prefix:
First Name:VINCIA
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 1:9441 LBJ FRWY
Mailing Address - Street 2:# 602
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9441 LBJ FRWY
Practice Address - Street 2:# 602
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243
Practice Address - Country:US
Practice Address - Phone:469-249-1883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00084481246W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246W00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Cardiology