Healthcare Provider Details

I. General information

NPI: 1518965300
Provider Name (Legal Business Name): ELIZABETH A. MONTGOMERY CRNP-A
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 MEDICAL PKWY SUITE 430
ANNAPOLIS MD
21401-3046
US

IV. Provider business mailing address

PO BOX 64531
BALTIMORE MD
21264-4531
US

V. Phone/Fax

Practice location:
  • Phone: 410-266-2720
  • Fax: 410-224-0209
Mailing address:
  • Phone: 410-280-6568
  • Fax: 410-280-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR043688
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: