Healthcare Provider Details

I. General information

NPI: 1720053416
Provider Name (Legal Business Name): CAROLYN A MONTGOMERY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 LA RIVIERE DR STE 201
BUFFALO NY
14202-4344
US

IV. Provider business mailing address

40 LA RIVIERE DR STE 201
BUFFALO NY
14202-4344
US

V. Phone/Fax

Practice location:
  • Phone: 716-893-1010
  • Fax: 716-893-1002
Mailing address:
  • Phone: 716-893-1010
  • Fax: 716-893-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberF340627
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: