Provider Demographics
NPI:1124697495
Name:MONTGOMERY, EMILY RAE (APRN)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:RAE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:RAE
Other - Last Name:GOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:049-697-4100
Mailing Address - Fax:
Practice Address - Street 1:6535 NEMOURS PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7884
Practice Address - Country:US
Practice Address - Phone:407-567-4000
Practice Address - Fax:407-567-5924
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11010426363LP0200X
FL11010426363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics