MEDICARE: MS. MARJA LYNN MONTAGUE LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	P114387	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2618859	OTHER	OH	INDEPENDENT PROVIDER NMBR

General Provider Information

NPI Number	:	1003931684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARJA LYNN MONTAGUE LPN

Provider Business Mailing Address
First Line	:	2308 HINDE RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43607-3518
Country	:	US
Telephone Number	:	419-531-3776
Fax Number	:

Provider Business Practice Location Address
First Line	:	2308 HINDE RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43607-3518
Country	:	US
Telephone Number	:	419-531-3776
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	07/08/2007

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