Provider Demographics
NPI:1700489911
Name:STEWART, MONTANA FAITH
Entity Type:Individual
Prefix:
First Name:MONTANA
Middle Name:FAITH
Last Name:STEWART
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:PO BOX 494
Mailing Address - Street 2:
Mailing Address - City:BOLT
Mailing Address - State:WV
Mailing Address - Zip Code:25817-0494
Mailing Address - Country:US
Mailing Address - Phone:304-250-5641
Mailing Address - Fax:
Practice Address - Street 1:108 BINGEN COURT
Practice Address - Street 2:
Practice Address - City:BOLT
Practice Address - State:WV
Practice Address - Zip Code:25817
Practice Address - Country:US
Practice Address - Phone:304-250-5641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty