Provider Demographics
NPI:1578898391
Name:MONTGOMERY, CRYSTAL A (FNP)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:A
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15820 DAKOTA ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-2329
Mailing Address - Country:US
Mailing Address - Phone:574-298-7797
Mailing Address - Fax:
Practice Address - Street 1:1600 SAINT JOHNS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1190
Practice Address - Country:US
Practice Address - Phone:651-232-5354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2059363LF0000X, 363LF0000X
IN7100314A363LF0000X
IN28171696A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily