Provider Demographics
NPI:1427059559
Name:MONTGOMERY, HEATHER JEAN (CRNP)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:JEAN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 HOSPITAL RD 200
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4055
Mailing Address - Country:US
Mailing Address - Phone:410-535-4561
Mailing Address - Fax:
Practice Address - Street 1:110 HOSPITAL RD
Practice Address - Street 2:SUITE 111
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4019
Practice Address - Country:US
Practice Address - Phone:410-535-4488
Practice Address - Fax:410-535-6131
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR137571207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD120363OtherJHHC PROVIDER NUMBER
MD61760401OtherCAREFIRST MD RENDERING
MD400427200Medicaid
MDR137571OtherMHIP PROVIDER ID
MD7605-0058OtherCAREFIRST BLUECHOICE
MD400427200Medicaid
P77485Medicare UPIN