Healthcare Provider Details

I. General information

NPI: 1417697244
Provider Name (Legal Business Name): ALEXANDRA CHANEL MONTGOMERY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 PROVIDENCE RD STE 100
CHARLOTTE NC
28207-1247
US

IV. Provider business mailing address

130 PROVIDENCE RD STE 100
CHARLOTTE NC
28207-1247
US

V. Phone/Fax

Practice location:
  • Phone: 704-333-9112
  • Fax: 704-333-9757
Mailing address:
  • Phone: 704-333-9112
  • Fax: 704-333-9757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2026-02562
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: