Provider Demographics
NPI:1114678380
Name:MONTAGUE, HANNAH JASMINE
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:JASMINE
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3051
Mailing Address - Country:US
Mailing Address - Phone:863-299-1107
Mailing Address - Fax:
Practice Address - Street 1:160 HERITAGE WAY STE 103
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3127
Practice Address - Country:US
Practice Address - Phone:406-871-6226
Practice Address - Fax:406-758-7925
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MTMED-PAC-LIC-117415363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant