Provider Demographics
NPI:1548671472
Name:FOUNTAIN, KATIE DIANA (PA-C)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:DIANA
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 911589
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1589
Mailing Address - Country:US
Mailing Address - Phone:505-923-6100
Mailing Address - Fax:505-923-6698
Practice Address - Street 1:1825 MARTHA BERRY BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1625
Practice Address - Country:US
Practice Address - Phone:706-295-5331
Practice Address - Fax:706-235-3104
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2017-07-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA007228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant