Provider Demographics
NPI:1942747530
Name:MONTENEGRO, VIRGINIA LOPEZ (RN)
Entity Type:Individual
Prefix:MISS
First Name:VIRGINIA
Middle Name:LOPEZ
Last Name:MONTENEGRO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4352
Mailing Address - Country:US
Mailing Address - Phone:315-486-4298
Mailing Address - Fax:
Practice Address - Street 1:167 POLK ST STE 300
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2770
Practice Address - Country:US
Practice Address - Phone:315-782-7445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY715891-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse