Provider Demographics
NPI:1730356668
Name:LAFOUNTAIN, GINA M (NP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:LAFOUNTAIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:M
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:350 7TH ST N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5754
Mailing Address - Country:US
Mailing Address - Phone:239-624-3997
Mailing Address - Fax:239-624-8101
Practice Address - Street 1:350 7TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5754
Practice Address - Country:US
Practice Address - Phone:239-624-3997
Practice Address - Fax:239-624-8101
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430227-1207P00000X
FLARNP9429700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02580321Medicaid
FLP8REWOtherBCBS
FLPENDINGMedicaid
FLPENDINGMedicare PIN