Provider Demographics
NPI:1225679012
Name:MONTGOMERY, JANESSA ANNETTE (DNP)
Entity Type:Individual
Prefix:
First Name:JANESSA
Middle Name:ANNETTE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:JANESSA
Other - Middle Name:ANNETTE
Other - Last Name:FREEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:332 ROCK RIDGE RD NW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52405-5307
Mailing Address - Country:US
Mailing Address - Phone:319-389-4295
Mailing Address - Fax:
Practice Address - Street 1:5510 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2946
Practice Address - Country:US
Practice Address - Phone:563-424-2025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC154761363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAC154761OtherSTATE LICENSE