Provider Demographics
NPI:1831981331
Name:MONTGOMERY, LESLIE GINEVRA I
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:GINEVRA
Last Name:MONTGOMERY
Suffix:I
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 1:11259 SOPRIS LOOP
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-1009
Mailing Address - Country:US
Mailing Address - Phone:208-703-7729
Mailing Address - Fax:208-703-7729
Practice Address - Street 1:700 PARKSIDE WAY
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-8247
Practice Address - Country:US
Practice Address - Phone:208-703-7729
Practice Address - Fax:208-703-7729
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCFH-6633171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor