Provider Demographics
NPI:1538720388
Name:MONTGOMERY, NADIA L
Entity type:Individual
Prefix:
First Name:NADIA
Middle Name:L
Last Name:MONTGOMERY
Suffix:
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 1:2925A DOVE HAVEN CT # A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-7314
Mailing Address - Country:US
Mailing Address - Phone:843-751-0424
Mailing Address - Fax:
Practice Address - Street 1:2925A DOVE HAVEN CT # A
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-7314
Practice Address - Country:US
Practice Address - Phone:843-751-0424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-1042374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCIHCP-1042OtherDHEC LICENSE NUMBER