Provider Demographics
NPI:1336148808
Name:MONTGOMERY, DIANA LYNN
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:LYNN
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 1:60 LONG AVE
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:TN
Mailing Address - Zip Code:38363-2429
Mailing Address - Country:US
Mailing Address - Phone:731-847-3676
Mailing Address - Fax:731-847-6290
Practice Address - Street 1:60 LONG AVE
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:TN
Practice Address - Zip Code:38363-2429
Practice Address - Country:US
Practice Address - Phone:731-847-3676
Practice Address - Fax:731-847-6290
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN31635OtherTLC
TN4021848OtherBCBS
TN31635OtherTLC