Provider Demographics
NPI:1992009757
Name:MONTGOMERY, KESHEA LANELL (BS- QP)
Entity Type:Individual
Prefix:
First Name:KESHEA
Middle Name:LANELL
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:BS- QP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 PINEVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407
Mailing Address - Country:US
Mailing Address - Phone:336-327-6862
Mailing Address - Fax:
Practice Address - Street 1:2406 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-4730
Practice Address - Country:US
Practice Address - Phone:336-327-6862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24312062172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver