Provider Demographics
NPI:1306965926
Name:MONTANEZ, ISMARI
Entity type:Individual
Prefix:
First Name:ISMARI
Middle Name:
Last Name:MONTANEZ
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:PO BOX 2072
Mailing Address - Street 2:
Mailing Address - City:COLLEGEDALE
Mailing Address - State:TN
Mailing Address - Zip Code:37315-2072
Mailing Address - Country:US
Mailing Address - Phone:423-227-8955
Mailing Address - Fax:
Practice Address - Street 1:362 CALLEN LN NW
Practice Address - Street 2:SUITE 110
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-3784
Practice Address - Country:US
Practice Address - Phone:423-331-5025
Practice Address - Fax:423-698-0511
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000147736163W00000X
TN22663363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ029115Medicaid