Healthcare Provider Details

I. General information

NPI: 1912677659
Provider Name (Legal Business Name): ELIZABETH ANNE MONTGOMERY IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10501 E 91ST ST
TULSA OK
74133-5888
US

IV. Provider business mailing address

3102 S NARCISSUS PL
BROKEN ARROW OK
74012-6845
US

V. Phone/Fax

Practice location:
  • Phone: 918-307-6394
  • Fax:
Mailing address:
  • Phone: 918-430-4985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberR0102187
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: