Provider Demographics
NPI:1609466770
Name:MONTGOMERY, KELLY NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:25700 SCIENCE PARK DR STE 210
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7328
Mailing Address - Country:US
Mailing Address - Phone:216-450-1613
Mailing Address - Fax:216-450-1614
Practice Address - Street 1:3591 RESERVE COMMONS DR STE 100
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-5334
Practice Address - Country:US
Practice Address - Phone:216-450-1613
Practice Address - Fax:216-450-1614
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0028297363LF0000X, 363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner