Healthcare Provider Details

I. General information

NPI: 1588297873
Provider Name (Legal Business Name): KIA DANIELLE MONTGOMERY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2020
Last Update Date: 10/26/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W WOODROW WILSON AVE STE 411
JACKSON MS
39213-7681
US

IV. Provider business mailing address

350 W WOODROW WILSON AVE STE 411
JACKSON MS
39213-7681
US

V. Phone/Fax

Practice location:
  • Phone: 601-432-3070
  • Fax: 601-364-2659
Mailing address:
  • Phone: 601-432-3070
  • Fax: 601-364-2659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number893817
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number893817
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number904981
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: