Provider Demographics
NPI:1992784656
Name:MONTGOMERY, COURTNEY LAIRD (ARNP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LAIRD
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LAIRD
Other - Last Name:DECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1031
Mailing Address - Street 2:
Mailing Address - City:FALL CITY
Mailing Address - State:WA
Mailing Address - Zip Code:98024-1031
Mailing Address - Country:US
Mailing Address - Phone:425-222-5778
Mailing Address - Fax:425-644-7318
Practice Address - Street 1:4140 FACTORIA BLVD SE
Practice Address - Street 2:SUITE A
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-5261
Practice Address - Country:US
Practice Address - Phone:425-644-2273
Practice Address - Fax:425-644-7318
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007068363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8875003Medicare UPIN