Provider Demographics
NPI:1003319823
Name:MONTGOMERY, PENNY ANN (LVN)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:ANN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 973
Mailing Address - Street 2:
Mailing Address - City:INGLESIDE
Mailing Address - State:TX
Mailing Address - Zip Code:78362-0973
Mailing Address - Country:US
Mailing Address - Phone:361-446-1070
Mailing Address - Fax:
Practice Address - Street 1:800 N SHORELINE BLVD STE 700
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78401-3771
Practice Address - Country:US
Practice Address - Phone:361-937-7887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-18
Last Update Date:2018-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX179415164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse