Provider Demographics
NPI:1932410248
Name:MONTGOMERY, TAMARA (LPN)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LPN
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 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4560
Mailing Address - Fax:520-682-4570
Practice Address - Street 1:13549 N SANDERS RD
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653-9505
Practice Address - Country:US
Practice Address - Phone:520-682-1095
Practice Address - Fax:520-682-4132
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP043753164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse