Healthcare Provider Details

I. General information

NPI: 1740016773
Provider Name (Legal Business Name): BRANDY MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 HIGHWAY 15 S
PONTOTOC MS
38863-2628
US

IV. Provider business mailing address

109 HIGHWAY 15 S
PONTOTOC MS
38863-2628
US

V. Phone/Fax

Practice location:
  • Phone: 662-509-9934
  • Fax:
Mailing address:
  • Phone: 662-509-9934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number906930
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: