Provider Demographics
NPI:1124186507
Name:MONTGOMERY, CHANDRA L (NP)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:L
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1174 IDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-5238
Mailing Address - Country:US
Mailing Address - Phone:254-214-2558
Mailing Address - Fax:254-582-5518
Practice Address - Street 1:1174 IDLEWOOD DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-5238
Practice Address - Country:US
Practice Address - Phone:254-214-2558
Practice Address - Fax:254-582-5518
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX636019363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Z020Medicare PIN
8F7819Medicare UPIN