Provider Demographics
NPI:1710505649
Name:MONTGOMERY, LACRISTA (SPECIALUST)
Entity Type:Individual
Prefix:
First Name:LACRISTA
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:SPECIALUST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 WOODGREEN RD APT 23
Mailing Address - Street 2:
Mailing Address - City:PLANTERSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38862-9709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-5748
Practice Address - Country:US
Practice Address - Phone:662-422-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00596591744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0059659OtherSPECIALIST