Provider Demographics
NPI:1942873617
Name:MONTGOMERY, CHARISSE MICHELLE
Entity Type:Individual
Prefix:
First Name:CHARISSE
Middle Name:MICHELLE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1274 BAYBROOK CT
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-7980
Mailing Address - Country:US
Mailing Address - Phone:618-250-7792
Mailing Address - Fax:
Practice Address - Street 1:1274 BAYBROOK CT
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-7980
Practice Address - Country:US
Practice Address - Phone:618-250-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty