MEDICARE: KINA 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
1	363LF0000X	Family Nurse Practitioner	209.011493	IL

General Provider Information

NPI Number	:	1548671399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KINA MONTGOMERY

Provider Business Mailing Address
First Line	:	138 N AUSTIN BLVD
Second Line	:	APT 3A
City	:	OAK PARK
State	:	IL
Zip	:	60302-3338
Country	:	US
Telephone Number	:	773-343-5539
Fax Number	:

Provider Business Practice Location Address
First Line	:	138 N AUSTIN BLVD
Second Line	:	APT 3A
City	:	OAK PARK
State	:	IL
Zip	:	60302-3338
Country	:	US
Telephone Number	:	773-343-5539
Fax Number	:

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

Provider Enumeration Date	:	05/14/2014
Last Update Date	:	01/17/2017

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Directions to “ KINA MONTGOMERY ” Practice Location

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