Provider Demographics
NPI:1164404166
Name:MONTGOMERY, CHARLOTTE (FNP)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:727 S MAIN ST
Mailing Address - Street 2:PO BOX 536
Mailing Address - City:MIDDLETON
Mailing Address - State:TN
Mailing Address - Zip Code:38052-3607
Mailing Address - Country:US
Mailing Address - Phone:731-376-2804
Mailing Address - Fax:731-376-2806
Practice Address - Street 1:727 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:TN
Practice Address - Zip Code:38052-3607
Practice Address - Country:US
Practice Address - Phone:731-376-2804
Practice Address - Fax:731-376-2806
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000005776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3928238Medicaid
TN3928238Medicaid
Q12314Medicare UPIN