Provider Demographics
NPI:1407009665
Name:MONTGOMERY, MARYALICE (RN CNOR RNFA)
Entity Type:Individual
Prefix:MRS
First Name:MARYALICE
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:RN CNOR RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21309 LOWLAND AVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-9565
Mailing Address - Country:US
Mailing Address - Phone:907-622-6222
Mailing Address - Fax:
Practice Address - Street 1:21309 LOWLAND AVE
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-9565
Practice Address - Country:US
Practice Address - Phone:907-622-6222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK24088163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant