Healthcare Provider Details

I. General information

NPI: 1790382448
Provider Name (Legal Business Name): MEGAN MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E FERGUSON ST STE 608
TYLER TX
75702-5756
US

IV. Provider business mailing address

1504 LUCY CIR
LINDALE TX
75771-6625
US

V. Phone/Fax

Practice location:
  • Phone: 903-705-0070
  • Fax: 903-405-3932
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number1009940
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: