Provider Demographics
NPI:1699849760
Name:MONTGOMERY, NICOLE N (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:N
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 1:5565 LINDERO CANYON RD
Mailing Address - Street 2:SUITE 405
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362
Mailing Address - Country:US
Mailing Address - Phone:818-707-1768
Mailing Address - Fax:
Practice Address - Street 1:5565 LINDERO CANYON RD
Practice Address - Street 2:SUITE 405
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362
Practice Address - Country:US
Practice Address - Phone:818-707-1768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA709263163WP0808X
TNAPN0000012290363LP0808X
CA18001363LP0808X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
3724297Medicare PIN