Provider Demographics
NPI:1033748322
Name:MONTGOMERY, CECILY A (ARNP)
Entity Type:Individual
Prefix:
First Name:CECILY
Middle Name:A
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 YAKIMA AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5305
Mailing Address - Country:US
Mailing Address - Phone:253-627-1244
Mailing Address - Fax:253-426-6344
Practice Address - Street 1:1802 YAKIMA AVE STE 304
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5305
Practice Address - Country:US
Practice Address - Phone:253-627-1244
Practice Address - Fax:253-426-6344
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61044813363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2156646Medicaid