Provider Demographics
NPI:1982131991
Name:MONTGOMERY, ASHLEY ANTIONETTE (LPN)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ANTIONETTE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 KIRKMAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1409 KIRKMAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-419-3583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
LA20122542164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse