Provider Demographics
NPI:1164147187
Name:MONTGOMERY, TYWANNA JAYE
Entity Type:Individual
Prefix:
First Name:TYWANNA
Middle Name:JAYE
Last Name:MONTGOMERY
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 1:9435 TEMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-3033
Mailing Address - Country:US
Mailing Address - Phone:813-810-1103
Mailing Address - Fax:
Practice Address - Street 1:801 W BAY DR STE 605
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3268
Practice Address - Country:US
Practice Address - Phone:727-489-3305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11022335207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty