Provider Demographics
NPI:1689820623
Name:MONTGOMERY, VANESSA KAYE (LPN)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:KAYE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:OH
Mailing Address - Zip Code:44890-1015
Mailing Address - Country:US
Mailing Address - Phone:419-935-0340
Mailing Address - Fax:
Practice Address - Street 1:121 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:OH
Practice Address - Zip Code:44890-1015
Practice Address - Country:US
Practice Address - Phone:419-935-0340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN118565 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse