Provider Demographics
NPI:1598710063
Name:MONTRIE, DEIDRA (CRNA)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:MONTRIE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5759 HOME LN
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-1808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2409 CHERRY ST #305
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608
Practice Address - Country:US
Practice Address - Phone:419-251-3740
Practice Address - Fax:419-251-3859
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH278694174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2620006Medicaid
OH2620006Medicaid