Healthcare Provider Details

I. General information

NPI: 1154230688
Provider Name (Legal Business Name): PENELOPE MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 SOUTHCREST CIR STE 200
SOUTHAVEN MS
38671-6729
US

IV. Provider business mailing address

391 SOUTHCREST CIR STE 200
SOUTHAVEN MS
38671-6729
US

V. Phone/Fax

Practice location:
  • Phone: 901-271-1000
  • Fax: 662-996-1209
Mailing address:
  • Phone: 901-271-1000
  • Fax: 662-996-1209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number857656
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: