Healthcare Provider Details

I. General information

NPI: 1023783115
Provider Name (Legal Business Name): MARIA MONTGOMERY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7821 S PAXTON AVE APT 3
CHICAGO IL
60649-5063
US

IV. Provider business mailing address

7821 S PAXTON AVE APT 3
CHICAGO IL
60649-5063
US

V. Phone/Fax

Practice location:
  • Phone: 773-820-2292
  • Fax:
Mailing address:
  • Phone: 773-820-2292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number041444492
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: