Provider Demographics
NPI:1629203310
Name:MONTGOMERY, HEATHER COLLINS (FNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:COLLINS
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 1:6918 SHALLOWFORD RD
Mailing Address - Street 2:STE 206
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1782
Mailing Address - Country:US
Mailing Address - Phone:423-802-1919
Mailing Address - Fax:423-269-6178
Practice Address - Street 1:6106 SHALLOWFORD RD STE 104
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:423-802-1919
Practice Address - Fax:423-269-6178
Is Sole Proprietor?:No
Enumeration Date:2009-05-25
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14126363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA130529501FMedicaid
TN1517467Medicaid
2009001637OtherANCC CERTIFICATION
TN103I502383Medicare PIN