MEDICARE: HANNAH NICOLE MONTGOMERY

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1225667082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HANNAH NICOLE MONTGOMERY

Provider Business Mailing Address
First Line	:	405 E 16TH ST
Second Line	:
City	:	HOPE
State	:	AR
Zip	:	71801-8304
Country	:	US
Telephone Number	:	870-397-4231
Fax Number	:

Provider Business Practice Location Address
First Line	:	1525 MERRILL DR
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72211-1821
Country	:	US
Telephone Number	:	501-228-0063
Fax Number	:

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

Provider Enumeration Date	:	04/03/2020
Last Update Date	:	04/03/2020

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