Provider Demographics
NPI:1649239922
Name:MONTGOMERY, GINI M (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:GINI
Middle Name:M
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10939 AL HWY 157
Mailing Address - Street 2:
Mailing Address - City:MOULTON
Mailing Address - State:AL
Mailing Address - Zip Code:35650
Mailing Address - Country:US
Mailing Address - Phone:256-974-8440
Mailing Address - Fax:256-974-6993
Practice Address - Street 1:10939 AL HWY 157
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:AL
Practice Address - Zip Code:35650
Practice Address - Country:US
Practice Address - Phone:256-974-8440
Practice Address - Fax:256-974-6993
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1075886363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P54988Medicare UPIN