Provider Demographics
NPI:1427686591
Name:MONTGOMERY, ANGELA M
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:MONTGOMERY
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 1:118 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2832
Mailing Address - Country:US
Mailing Address - Phone:636-224-1210
Mailing Address - Fax:
Practice Address - Street 1:4600 MCMASTERS AVE
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-2244
Practice Address - Country:US
Practice Address - Phone:573-603-1460
Practice Address - Fax:573-603-1462
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999135122164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse