Provider Demographics
NPI:1649672056
Name:MONTGOMERY, KERI H (NP)
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:H
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 WASHINGTON AVE # 100
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 WASHINGTON AVE
Practice Address - Street 2:STE 100
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0550
Practice Address - Country:US
Practice Address - Phone:812-485-6694
Practice Address - Fax:812-485-7678
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005783A363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201324670Medicaid
ININ1776154Medicare PIN