Provider Demographics
NPI:1790846475
Name:MONTGOMERY, MARY L (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 LAKE CITY WAY NE
Mailing Address - Street 2:COMMUNITY PSYCHIATRIC CLINIC
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-6748
Mailing Address - Country:US
Mailing Address - Phone:206-461-3614
Mailing Address - Fax:206-634-3596
Practice Address - Street 1:2329 4TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-1717
Practice Address - Country:US
Practice Address - Phone:206-461-3649
Practice Address - Fax:206-461-8391
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005664363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P93802Medicare UPIN
AB38423Medicare ID - Type Unspecified