Provider Demographics
NPI:1508368200
Name:MONTGOMERY, STACY (CST, CSFA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:CST, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22034 COUNTY ROAD 2166
Mailing Address - Street 2:
Mailing Address - City:TROUP
Mailing Address - State:TX
Mailing Address - Zip Code:75789-6900
Mailing Address - Country:US
Mailing Address - Phone:903-780-9587
Mailing Address - Fax:888-501-1092
Practice Address - Street 1:22034 COUNTY ROAD 2166
Practice Address - Street 2:
Practice Address - City:TROUP
Practice Address - State:TX
Practice Address - Zip Code:75789-6900
Practice Address - Country:US
Practice Address - Phone:903-780-9587
Practice Address - Fax:888-501-1092
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant