Healthcare Provider Details

I. General information

NPI: 1699849760
Provider Name (Legal Business Name): NICOLE N MONTGOMERY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 LINDERO CANYON RD SUITE 405
WESTLAKE VILLAGE CA
91362
US

IV. Provider business mailing address

5565 LINDERO CANYON RD SUITE 405
WESTLAKE VILLAGE CA
91362
US

V. Phone/Fax

Practice location:
  • Phone: 818-707-1768
  • Fax:
Mailing address:
  • Phone: 818-707-1768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN0000012290
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number18001
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number709263
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: