Provider Demographics
NPI:1043290323
Name:MONTGOMERY, MICHELLE (WHNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 VINCENT ST
Mailing Address - Street 2:FAMILY PRACTICE CLINIC
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1541
Mailing Address - Country:US
Mailing Address - Phone:719-556-1080
Mailing Address - Fax:719-556-1266
Practice Address - Street 1:559 VINCENT ST
Practice Address - Street 2:FAMILY PRACTICE CLINIC
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914-1540
Practice Address - Country:US
Practice Address - Phone:719-556-1080
Practice Address - Fax:719-556-1266
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002007463363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health