Provider Demographics
NPI:1649258922
Name:MONTAGUE, MARY T (CNS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:T
Other - Last Name:SOPKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-444-1878
Mailing Address - Fax:216-636-0455
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-444-1878
Practice Address - Fax:216-636-0455
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNS08605364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist