Provider Demographics
NPI:1851345854
Name:MONTGOMERY, REBECCA M (CNM)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 HERCULES DR STE 110
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-5838
Mailing Address - Country:US
Mailing Address - Phone:802-448-9719
Mailing Address - Fax:802-660-9435
Practice Address - Street 1:90 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-4239
Practice Address - Country:US
Practice Address - Phone:802-476-6696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010024494367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007432Medicaid
VT1007432Medicaid
VTVN2692Medicare PIN
VT4000034Medicaid