Provider Demographics
NPI:1508837774
Name:MONTGOMERY, ROBERTA J (CNP)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:J
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2537
Mailing Address - Country:US
Mailing Address - Phone:320-762-0399
Mailing Address - Fax:320-762-6847
Practice Address - Street 1:1527 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2537
Practice Address - Country:US
Practice Address - Phone:320-762-0399
Practice Address - Fax:320-762-6847
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1401381363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN857963OtherAMERICA'S PPO
MNA020OtherCHAMPUS
MNHP34223OtherHEALTH PARTNERS
MN731528700Medicaid
MN0107835OtherMEDICA
MN1022855OtherPREFERRED ONE
MN140897D277OtherUCARE
MN51G60MOOtherBLUE SHIELD
MN857963OtherAMERICA'S PPO
MN731528700Medicaid