Provider Demographics
NPI:1477247419
Name:MONTGOMERY, MAKIA MONIQUE
Entity Type:Individual
Prefix:MS
First Name:MAKIA
Middle Name:MONIQUE
Last Name:MONTGOMERY
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 1:4753 S HARVARD AVE APT 28
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3012
Mailing Address - Country:US
Mailing Address - Phone:918-960-8422
Mailing Address - Fax:
Practice Address - Street 1:4753 S HARVARD AVE APT 28
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3012
Practice Address - Country:US
Practice Address - Phone:918-960-8422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator