Healthcare Provider Details

I. General information

NPI: 1578898391
Provider Name (Legal Business Name): CRYSTAL A MONTGOMERY F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2009
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SAINT JOHNS BLVD STE 101
MAPLEWOOD MN
55109-1190
US

IV. Provider business mailing address

15820 DAKOTA ST NW
ANDOVER MN
55304-2329
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-5354
  • Fax:
Mailing address:
  • Phone: 574-298-7797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number2059
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2059
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: