Provider Demographics
NPI:1568802940
Name:MONTGOMERY, KIMBERLY DAWN (AGACNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 COLLEGE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3000
Mailing Address - Country:US
Mailing Address - Phone:817-336-6000
Mailing Address - Fax:817-336-2072
Practice Address - Street 1:1400 8TH AVE BLDG C
Practice Address - Street 2:SUITE 3001
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:817-922-2173
Practice Address - Fax:817-922-1047
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX665885364SA2200X
TX1074250363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX318215YMNTMedicare PIN