Basic Information
| Provider Information | |||||||||
| NPI: | 1871728436 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | RENA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 WOLF PARK DR | ||||||||
| Address2: | STE 103 | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381381759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012523400 | ||||||||
| FaxNumber: | 9017634305 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 GUTHRIE DR | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386715829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012523400 | ||||||||
| FaxNumber: | 9017634305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2009 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN14046 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364SW0102X | APN14046 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Women's Health |
No ID Information.