Provider Demographics
NPI:1821489568
Name:MONTGOMERY, MELINDA MARIE (NP-C)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:MARIE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3965 75TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7925
Mailing Address - Country:US
Mailing Address - Phone:630-375-1625
Mailing Address - Fax:630-375-1925
Practice Address - Street 1:3965 75TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7925
Practice Address - Country:US
Practice Address - Phone:630-375-1625
Practice Address - Fax:630-375-1925
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012590363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily