Provider Demographics
NPI:1629531595
Name:MONTGOMERY, EBONY MONIQUE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:MONIQUE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12216 AMARANTH DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117-9753
Mailing Address - Country:US
Mailing Address - Phone:501-319-3256
Mailing Address - Fax:
Practice Address - Street 1:1410 BRADEN STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076
Practice Address - Country:US
Practice Address - Phone:870-280-2578
Practice Address - Fax:844-447-2520
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR125407363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care