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General NPI Number Information
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NPI Number | 1629531595
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Entity Type | Individual
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Provider Name | EBONY MONIQUE MONTGOMERY APRN
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Gender | Female
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Dates
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Enumeration Date | 04/08/2019
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Last Update Date | 02/26/2025
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Provider Practice Location Address
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Address Line | 1410 BRADEN STREET
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City | JACKSONVILLE
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State | AR
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Zip | 72076
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Country | US
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Telephone | 870-280-2578
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Fax | 844-447-2520
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Provider Business Mailing Address
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Address Line | 500 SW 7TH ST STEA205
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City | RENTON
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State | WA
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Zip | 98057
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Country | US
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Telephone | 877-522-1275
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Fax | 833-888-7145
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 125407
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License Number State | AR
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