Provider Demographics
NPI:1578159133
Name:MONTGOMERY, QUIANA
Entity Type:Individual
Prefix:
First Name:QUIANA
Middle Name:
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 1:7905 RUGBY ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-2511
Mailing Address - Country:US
Mailing Address - Phone:215-834-7087
Mailing Address - Fax:
Practice Address - Street 1:7905 RUGBY ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19150-2511
Practice Address - Country:US
Practice Address - Phone:215-834-7087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA51743601374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA51743601OtherHOME HEALTH LICENSE NUMBER