Provider Demographics
NPI:1427263524
Name:MONTAVON, VIRGINIA LEE
Entity type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:LEE
Last Name:MONTAVON
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 1:75 SIMON MILLER RD
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-8450
Mailing Address - Country:US
Mailing Address - Phone:740-776-7191
Mailing Address - Fax:
Practice Address - Street 1:1719 HUTCHINS ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3159
Practice Address - Country:US
Practice Address - Phone:740-354-6559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2581899Medicaid