Provider Demographics
NPI:1033840350
Name:MONTGOMERY, AVANLEIGH (PTA)
Entity Type:Individual
Prefix:
First Name:AVANLEIGH
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 46TH STREET CT W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6658
Mailing Address - Country:US
Mailing Address - Phone:253-509-4466
Mailing Address - Fax:
Practice Address - Street 1:613 S KNIK GOOSE BAY RD STE E
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8090
Practice Address - Country:US
Practice Address - Phone:907-317-5895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60975822225200000X
AK191274225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant