Provider Demographics
NPI:1306489414
Name:WRIGHT, MONTIA LATRESE
Entity type:Individual
Prefix:
First Name:MONTIA
Middle Name:LATRESE
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3623 W HEDGE HILL LN APT 1
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2581
Mailing Address - Country:US
Mailing Address - Phone:309-404-5318
Mailing Address - Fax:
Practice Address - Street 1:211 FULTON ST STE 207
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1332
Practice Address - Country:US
Practice Address - Phone:309-671-8580
Practice Address - Fax:309-671-7747
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide