Healthcare Provider Details

I. General information

NPI: 1184085268
Provider Name (Legal Business Name): BROOKE MONTGOMERY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2016
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 E FRONT ST STE A
LAUREL DE
19956-1725
US

IV. Provider business mailing address

116 E FRONT ST STE A
LAUREL DE
19956-1725
US

V. Phone/Fax

Practice location:
  • Phone: 765-265-1214
  • Fax:
Mailing address:
  • Phone: 302-280-6358
  • Fax: 302-280-6321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28160822A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28160822A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0011527
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: