Provider Demographics
NPI:1821877036
Name:MONTGOMERY, JOSEPH BRENT (LPN)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:BRENT
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41W400 SILVER GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-8453
Mailing Address - Country:US
Mailing Address - Phone:630-940-1100
Mailing Address - Fax:
Practice Address - Street 1:41W400 SILVER GLEN RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-8453
Practice Address - Country:US
Practice Address - Phone:630-940-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043109975164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse