Provider Demographics
NPI:1265029284
Name:DAVIS, MONTGOMERY
Entity Type:Individual
Prefix:
First Name:MONTGOMERY
Middle Name:
Last Name:DAVIS
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 1:53 MEADOW RIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6879
Mailing Address - Country:US
Mailing Address - Phone:870-718-4194
Mailing Address - Fax:
Practice Address - Street 1:53 MEADOW RIDGE LOOP
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-6879
Practice Address - Country:US
Practice Address - Phone:870-718-4194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR099213363L00000X
AR1031057367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered