Provider Demographics
NPI:1528695137
Name:MONTFORT, LATOYA VENISE (ACAGNP)
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:VENISE
Last Name:MONTFORT
Suffix:
Gender:F
Credentials:ACAGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2162 BOULDER GATE DR
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-1682
Mailing Address - Country:US
Mailing Address - Phone:678-536-8756
Mailing Address - Fax:
Practice Address - Street 1:250 SCENIC HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5675
Practice Address - Country:US
Practice Address - Phone:678-442-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN208269363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner