Provider Demographics
NPI:1508837774
Name:MONTGOMERY, ROBERTA J (CNP)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:J
Last Name:MONTGOMERY
Suffix:
Gender:
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 ELM ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2417
Mailing Address - Country:US
Mailing Address - Phone:701-239-3700
Mailing Address - Fax:
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:701-239-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1401381363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0107835OtherMEDICA
MN1022855OtherPREFERRED ONE
MNA020OtherCHAMPUS
MN857963OtherAMERICA'S PPO
MNHP34223OtherHEALTH PARTNERS
MN731528700Medicaid
MN140897D277OtherUCARE
MN51G60MOOtherBLUE SHIELD
MN857963OtherAMERICA'S PPO
MN731528700Medicaid