Provider Demographics
NPI:1447561345
Name:MONTGOMERY, SUSAN LEIGH (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEIGH
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WEISENBERGER ROAD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8561
Mailing Address - Country:US
Mailing Address - Phone:601-790-9080
Mailing Address - Fax:601-790-9098
Practice Address - Street 1:122 WEISENBERGER ROAD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8561
Practice Address - Country:US
Practice Address - Phone:601-790-9080
Practice Address - Fax:601-790-9098
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR524174363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116067Medicaid