MEDICARE: MARY BROWN MONTGOMERY CPNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	2022039874	MO

General Provider Information

NPI Number	:	1114704996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY BROWN MONTGOMERY CPNP

Provider Business Mailing Address
First Line	:	9415 HIGH HILL CT
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-2106
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9415 HIGH HILL CT
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-2106
Country	:	US
Telephone Number	:	314-458-2793
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2023
Last Update Date	:	09/13/2023

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