Provider Demographics
NPI:1346621075
Name:MONTGOMERY, LATRENA (FNP-C)
Entity Type:Individual
Prefix:
First Name:LATRENA
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1668 W PEACE ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-5332
Mailing Address - Country:US
Mailing Address - Phone:601-622-8182
Mailing Address - Fax:
Practice Address - Street 1:105 VARESE PL
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-622-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR881572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily