=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033840350
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVANLEIGH MONTGOMERY PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2022
-----------------------------------------------------
Last Update Date | 06/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 613 S KNIK GOOSE BAY RD STE E
-----------------------------------------------------
City | WASILLA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99654-8090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-317-5895
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5215 46TH STREET CT W
-----------------------------------------------------
City | UNIVERSITY PLACE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98466-6658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-509-4466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 60975822
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 191274
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------