Provider Demographics
NPI:1992912273
Name:MONTGOMERY, MARY D (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:466 OAK GROVE RD
Mailing Address - Street 2:
Mailing Address - City:DRESDEN
Mailing Address - State:TN
Mailing Address - Zip Code:38225-1748
Mailing Address - Country:US
Mailing Address - Phone:731-364-6934
Mailing Address - Fax:
Practice Address - Street 1:1010 MOUNT ZION RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-7694
Practice Address - Country:US
Practice Address - Phone:731-884-2645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000045259163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse