Provider Demographics
NPI:1013501303
Name:MONTGOMERY, NICOLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 SW FOXTAIL DR
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-9111
Mailing Address - Country:US
Mailing Address - Phone:417-926-2538
Mailing Address - Fax:
Practice Address - Street 1:829 SW LEMANS LN
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64082-4618
Practice Address - Country:US
Practice Address - Phone:816-352-9461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210061842251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics