Healthcare Provider Details

I. General information

NPI: 1043290323
Provider Name (Legal Business Name): MICHELLE MONTGOMERY WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 VINCENT ST FAMILY PRACTICE CLINIC
PETERSON AFB CO
80914-1540
US

IV. Provider business mailing address

559 VINCENT ST FAMILY PRACTICE CLINIC
COLORADO SPRINGS CO
80914-1541
US

V. Phone/Fax

Practice location:
  • Phone: 719-556-1080
  • Fax: 719-556-1266
Mailing address:
  • Phone: 719-556-1080
  • Fax: 719-556-1266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number2002007463
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: