Healthcare Provider Details

I. General information

NPI: 1699303388
Provider Name (Legal Business Name): MAKENNA MONTGOMERY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAKENNA MERKLEY

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 E BASELINE RD. STE 113
QUEEN CREEK AZ
85142-7444
US

IV. Provider business mailing address

3303 E BASELINE RD. STE 113
QUEEN CREEK AZ
85142
US

V. Phone/Fax

Practice location:
  • Phone: 480-369-7161
  • Fax:
Mailing address:
  • Phone: 480-369-7161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number239699
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: