Provider Demographics
NPI:1922108406
Name:MONTGOMERY, LAVERNE S (MA,RD, LD)
Entity Type:Individual
Prefix:MS
First Name:LAVERNE
Middle Name:S
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MA,RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MONTGOMERY'S STRATEGIC NUTRITION SERVICES
Mailing Address - Street 2:6066 LAKEVIEW OVERLOOK
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3461
Mailing Address - Country:US
Mailing Address - Phone:770-482-6594
Mailing Address - Fax:
Practice Address - Street 1:5255 SNAPFINGER PARK DR
Practice Address - Street 2:SUITE 110
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-4084
Practice Address - Country:US
Practice Address - Phone:770-981-2211
Practice Address - Fax:770-981-0208
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000993132700000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No132700000XDietary & Nutritional Service ProvidersDietary Manager