Provider Demographics
NPI:1861584005
Name:FONTAINE, BRIAN KENNETH (CRNA)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KENNETH
Last Name:FONTAINE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 SCARBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-4022
Mailing Address - Country:US
Mailing Address - Phone:401-725-7021
Mailing Address - Fax:
Practice Address - Street 1:62 AMARAL ST STE 100
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2205
Practice Address - Country:US
Practice Address - Phone:352-275-2064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN00008367500000X
MA241092367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered