Provider Demographics
NPI:1114788551
Name:MONTGOMERY, DESMOND L (RN)
Entity Type:Individual
Prefix:
First Name:DESMOND
Middle Name:L
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2729 QUARRY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-4955
Mailing Address - Country:US
Mailing Address - Phone:216-952-3273
Mailing Address - Fax:
Practice Address - Street 1:2729 QUARRY LAKE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-4955
Practice Address - Country:US
Practice Address - Phone:216-952-3273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN478490163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse