Provider Demographics
NPI:1801570965
Name:MONTGOMERY, ALCYONITA
Entity type:Individual
Prefix:
First Name:ALCYONITA
Middle Name:
Last Name:MONTGOMERY
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 1:934 PIERCE IVY CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-1316
Mailing Address - Country:US
Mailing Address - Phone:678-770-7158
Mailing Address - Fax:
Practice Address - Street 1:6001 CUMMING HWY
Practice Address - Street 2:
Practice Address - City:SUGAR HILL
Practice Address - State:GA
Practice Address - Zip Code:30518-6112
Practice Address - Country:US
Practice Address - Phone:678-546-4062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN272461363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily