Healthcare Provider Details

I. General information

NPI: 1932410248
Provider Name (Legal Business Name): TAMARA MONTGOMERY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13549 N SANDERS RD
MARANA AZ
85653-9505
US

IV. Provider business mailing address

PO BOX 188
MARANA AZ
85653-0188
US

V. Phone/Fax

Practice location:
  • Phone: 520-682-1095
  • Fax: 520-682-4132
Mailing address:
  • Phone: 520-682-4560
  • Fax: 520-682-4570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP043753
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: