Provider Demographics
NPI:1720593254
Name:MONTGOMERY, DELISHA MELVINIA
Entity Type:Individual
Prefix:
First Name:DELISHA
Middle Name:MELVINIA
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 CONNER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2201
Mailing Address - Country:US
Mailing Address - Phone:313-273-4111
Mailing Address - Fax:
Practice Address - Street 1:4401 CONNER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2201
Practice Address - Country:US
Practice Address - Phone:313-273-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider