Provider Demographics
NPI:1629635859
Name:MONTGOMERY, GWENDOLYN ELAINE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:ELAINE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3962 BUSBY MILL CT
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3962 BUSBY MILL CT
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2052
Practice Address - Country:US
Practice Address - Phone:404-314-7295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN176860363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care