Provider Demographics
NPI:1457356347
Name:MONTGOMERY, DIANA MICHELLE (APN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MICHELLE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1960
Mailing Address - Street 2:NEA BAPTIST CLINIC
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-483-6131
Mailing Address - Fax:870-483-2573
Practice Address - Street 1:305 W. MAIN STREET
Practice Address - Street 2:NEA BAPTIST CLINIC
Practice Address - City:TRUMANN
Practice Address - State:AR
Practice Address - Zip Code:72472
Practice Address - Country:US
Practice Address - Phone:870-483-6131
Practice Address - Fax:870-483-2573
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01699363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150983758Medicaid
AR5X730Medicare PIN
ARQ04102Medicare UPIN
ARQ04102Medicare UPIN