Healthcare Provider Details

I. General information

NPI: 1871728436
Provider Name (Legal Business Name): RENA D MONTGOMERY APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 GUTHRIE DR
SOUTHAVEN MS
38671-5829
US

IV. Provider business mailing address

1325 WOLF PARK DR STE 103
GERMANTOWN TN
38138-1759
US

V. Phone/Fax

Practice location:
  • Phone: 901-252-3400
  • Fax: 901-763-4305
Mailing address:
  • Phone: 901-252-3400
  • Fax: 901-763-4305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN14046
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code364SW0102X
TaxonomyWomen's Health Clinical Nurse Specialist
License NumberAPN14046
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: