Provider Demographics
NPI:1063041663
Name:MONTGOMERY, TANGALA SUE (LPN)
Entity Type:Individual
Prefix:
First Name:TANGALA
Middle Name:SUE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TANGALA
Other - Middle Name:SUE
Other - Last Name:QUILLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:19253 SLIGO RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43973-9660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19253 SLIGO RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:OH
Practice Address - Zip Code:43973-9660
Practice Address - Country:US
Practice Address - Phone:740-260-0821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH083268164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse