Basic Information
| Provider Information | |||||||||
| NPI: | 1457356347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1960 | ||||||||
| Address2: | NEA BAPTIST CLINIC | ||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724031960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704836131 | ||||||||
| FaxNumber: | 8704832573 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 W. MAIN STREET | ||||||||
| Address2: | NEA BAPTIST CLINIC | ||||||||
| City: | TRUMANN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704836131 | ||||||||
| FaxNumber: | 8704832573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | A01699 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 150983758 | 05 | AR | MEDICAID |