Provider Demographics
NPI:1912058082
Name:MONTAGUE, LORI ANN (APRN, BC, FNP)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:ANN
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:APRN, BC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 W BOTNER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-9462
Mailing Address - Country:US
Mailing Address - Phone:573-443-3653
Mailing Address - Fax:
Practice Address - Street 1:423 E LOGAN ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-2222
Practice Address - Country:US
Practice Address - Phone:660-263-6643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO130816363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily