Healthcare Provider Details

I. General information

NPI: 1356006035
Provider Name (Legal Business Name): ESSENCE NICHOLE MONTGOMERY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 11/08/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5604 COLISEUM BLVD STE A
ALEXANDRIA LA
71303-3993
US

IV. Provider business mailing address

920 TWIN BRIDGES RD APT 64
ALEXANDRIA LA
71303-2072
US

V. Phone/Fax

Practice location:
  • Phone: 318-487-5282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number217766
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: