Provider Demographics
NPI:1104244763
Name:MONTGOMERY, STACEY LEIGH (ARNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LEIGH
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:890 W FARIS RD STE 580
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4281
Practice Address - Country:US
Practice Address - Phone:864-455-7874
Practice Address - Fax:864-455-8933
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9235897363LC0200X
SC26821363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid
FLARNP9235897OtherADVANCED REGISTERED NURSE PRACTITIONER