Healthcare Provider Details

I. General information

NPI: 1447896956
Provider Name (Legal Business Name): MS. SYDNEY NICOLE MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MEDICAL CENTER BLVD STE 250
LAWRENCEVILLE GA
30046-3402
US

IV. Provider business mailing address

500 MEDICAL CENTER BLVD STE 250
LAWRENCEVILLE GA
30046-3402
US

V. Phone/Fax

Practice location:
  • Phone: 770-979-4700
  • Fax: 770-979-1060
Mailing address:
  • Phone: 770-979-4700
  • Fax: 770-979-1060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License NumberRN259595
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN259595
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: