Basic Information
| Provider Information | |||||||||
| NPI: | 1629200902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | P. O. BOX 1821 | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437021821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404553304 | ||||||||
| FaxNumber: | 7404553686 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 COURT DRIVE | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404541248 | ||||||||
| FaxNumber: | 7404548183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2009 | ||||||||
| LastUpdateDate: | 05/23/2011 | ||||||||
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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 | 163WG0000X | RN241205 | OH | N | Nursing Service Providers | Registered Nurse | General Practice | 363L00000X | COA.10766-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3026988 | 05 | OH | MEDICAID | 3810019285 | 05 | WV | MEDICAID | P00914840 | 01 | OH | RR MEDICARE | OTHER |