Provider Demographics
NPI:1811972060
Name:MONTGOMERY, JEANETTE RUTH (CNP)
Entity type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:RUTH
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8487 COUNTY ROAD 107
Mailing Address - Street 2:
Mailing Address - City:NISSWA
Mailing Address - State:MN
Mailing Address - Zip Code:56468
Mailing Address - Country:US
Mailing Address - Phone:218-568-8485
Mailing Address - Fax:
Practice Address - Street 1:12647 OLIVE BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6345
Practice Address - Country:US
Practice Address - Phone:800-325-3982
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20040006-22363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily