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NPI Code Detail

MEDICARE: MARY MONTGOMERY

MEDICARE: MARY MONTGOMERY
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
1164W00000XLicensed Practical Nurse15311WV

General Provider Information

NPI Number : 1184846321
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY MONTGOMERY
Provider Business Mailing Address
First Line : PO BOX 60
Second Line :
City : GYPSY
State : WV
Zip : 26361-0060
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 706 OAKMOUND RD
Second Line :
City : CLARKSBURG
State : WV
Zip : 26301-9398
Country : US
Telephone Number : 304-622-7511
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/03/2007
Last Update Date : 07/08/2007

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Directions to “ MARY MONTGOMERY ” Practice Location

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