Healthcare Provider Details

I. General information

NPI: 1811972060
Provider Name (Legal Business Name): JEANETTE RUTH MONTGOMERY C.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12647 OLIVE BLVD SUITE 600
SAINT LOUIS MO
63141-6345
US

IV. Provider business mailing address

8487 COUNTY ROAD 107
NISSWA MN
56468
US

V. Phone/Fax

Practice location:
  • Phone: 800-325-3982
  • Fax:
Mailing address:
  • Phone: 218-568-8485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20040006-22
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: